1134546724 NPI number — SOUL SOLUTIONS, PLLC

Table of content: (NPI 1134546724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134546724 NPI number — SOUL SOLUTIONS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUL SOLUTIONS, PLLC
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:
6
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:
1134546724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6858 KINGSTON COVE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77318-9121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-283-1974
Provider Business Mailing Address Fax Number:
936-228-7994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 W MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRINITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75862-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-283-1974
Provider Business Practice Location Address Fax Number:
936-228-7994
Provider Enumeration Date:
03/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
409-283-1974

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  66084 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2303810 . This is a "COMPSYCH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 323797601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12618131 . This is a "CAQH ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 323797602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9203LL . This is a "BLUE CROSS BLUE CHIELD OF TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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