Basic Information
| Provider Information | |||||||||
| NPI: | 1588114870 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHOLE SELF WELLNESS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 627 NORWICH SALEM TPKE UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063701066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602220949 | ||||||||
| FaxNumber: | 8883265828 | ||||||||
| Practice Location | |||||||||
| Address1: | 627 NORWICH SALEM TPKE UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063701066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602220949 | ||||||||
| FaxNumber: | 8883265828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2016 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAMERON | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | STEPHANIE | ||||||||
| AuthorizedOfficialTitleorPosition: | APRN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8602220949 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APRN | ||||||||
| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 004768 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1356624027 | 01 | CT | NPI | OTHER |