1457724205 NPI number — BRAVE SOUL COUNSELING SERVICES

Table of content: (NPI 1457724205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457724205 NPI number — BRAVE SOUL COUNSELING SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAVE SOUL COUNSELING SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457724205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 BROADWAY AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PAUL PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55071-1554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-242-1224
Provider Business Mailing Address Fax Number:
651-340-2587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
445 BROADWAY AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PAUL PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55071-1554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-242-1224
Provider Business Practice Location Address Fax Number:
651-340-2587
Provider Enumeration Date:
11/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ELLINGSON
Authorized Official First Name:
JILL
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER & CLINICAL DIRECTOR
Authorized Official Telephone Number:
612-242-1224

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  2671 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com