Basic Information
| Provider Information | |||||||||
| NPI: | 1063157246 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLIDAY WHISENANT COUNSELING LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOLIDAY WHISENANT COUNSELING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1253 HOLLIDAY DR | ||||||||
| Address2: | |||||||||
| City: | GULF BREEZE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325632529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502208339 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1253 HOLLIDAY DR | ||||||||
| Address2: | |||||||||
| City: | GULF BREEZE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325632529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502208339 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2022 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHISENANT | ||||||||
| AuthorizedOfficialFirstName: | HOLIDAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8502873574 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMHC | ||||||||
| NPICertificationDate: | 11/10/2022 | ||||||||
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) |
ID Information
| ID | Type | State | Issuer | Description | 009555800 | 05 | FL | MEDICAID |