Provider Demographics
NPI:1588114870
Name:WHOLE SELF WELLNESS, LLC
Entity type:Organization
Organization Name:WHOLE SELF WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:STEPHANIE
Authorized Official - Last Name:DAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-222-0949
Mailing Address - Street 1:627 NORWICH SALEM TPKE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06370-1066
Mailing Address - Country:US
Mailing Address - Phone:860-222-0949
Mailing Address - Fax:888-326-5828
Practice Address - Street 1:627 NORWICH SALEM TPKE UNIT 2
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CT
Practice Address - Zip Code:06370-1066
Practice Address - Country:US
Practice Address - Phone:860-222-0949
Practice Address - Fax:888-326-5828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004768261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1356624027OtherNPI