1700383718 NPI number — WHOLE SOUL COUNSELING A LICENSED CLINICAL SOCIAL WORKER PC

Table of content: (NPI 1700383718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700383718 NPI number — WHOLE SOUL COUNSELING A LICENSED CLINICAL SOCIAL WORKER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHOLE SOUL COUNSELING A LICENSED CLINICAL SOCIAL WORKER PC
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:
1700383718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4005 MANZANITA AVENUE
Provider Second Line Business Mailing Address:
SUITE 6, #434
Provider Business Mailing Address City Name:
CARMICHAEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4125 TEMESCAL ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIR OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95628-7558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-877-6894
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MAHAKIAN
Authorized Official First Name:
LAUREN
Authorized Official Middle Name:
KRISTINA
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
916-877-6894

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  82146 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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