Provider Demographics
NPI:1689471013
Name:HER TABLE COLLECTIVE THERAPY & WELLNESS LLC
Entity type:Organization
Organization Name:HER TABLE COLLECTIVE THERAPY & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANCEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-565-9028
Mailing Address - Street 1:7314 MARY JO AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32409-4162
Mailing Address - Country:US
Mailing Address - Phone:850-565-9028
Mailing Address - Fax:
Practice Address - Street 1:7314 MARY JO AVE
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:FL
Practice Address - Zip Code:32409-4162
Practice Address - Country:US
Practice Address - Phone:850-565-9028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty