Provider Demographics
NPI:1295331114
Name:LOOSELEAF HOLISTIC WELLNESS
Entity type:Organization
Organization Name:LOOSELEAF HOLISTIC WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LETITIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURIEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:772-678-1397
Mailing Address - Street 1:290 NW PEACOCK BLVD UNIT 881444
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34988-5063
Mailing Address - Country:US
Mailing Address - Phone:772-208-8773
Mailing Address - Fax:
Practice Address - Street 1:3603 WILDERNESS DR E
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-6562
Practice Address - Country:US
Practice Address - Phone:772-208-8773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty