Basic Information
| Provider Information | |||||||||
| NPI: | 1043930993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHOLLY AUTHENTIC LIFE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 907 | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594360907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067992711 | ||||||||
| FaxNumber: | 4064673407 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 1ST AVE N | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594369245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067992711 | ||||||||
| FaxNumber: | 4064673407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2022 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | TAMMIE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MBR | ||||||||
| AuthorizedOfficialTelephone: | 4067992711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCPC | ||||||||
| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.