Organization
MY HOLISTIC LIFE, LLC
Active
Other names
My Holistic Life, LLC
Organization subpart
No
Provider details
NPI number
Authorized official
RONDA MAE WELTY COTA/L, CAPS (OWNER)
(901) 568-0442
Entity
Organization
Contact information
Practice address
10454 JUNEAU WAY, COLLIERVILLE, TN 38017-1968
(901) 568-0442
(901) 284-0008
Mailing address
10454 JUNEAU WAY, COLLIERVILLE, TN 38017-1968
(901) 568-0442
(901) 284-0008
Taxonomy
Speciality
Code
Description
License number
State
261QD1600X
Developmental Disabilities Clinic/Center
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1286
OTA LICENSE
TN
Enumeration date
07/30/2020
Last updated
07/30/2020
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