1982246286 NPI number — SOUL GROWTH PSYCHOLOGICAL SERVICES PLLC

Table of content: GABRIELLA MARIE IMPERATO M.S CF SLP (NPI 1679204887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982246286 NPI number — SOUL GROWTH PSYCHOLOGICAL SERVICES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUL GROWTH PSYCHOLOGICAL SERVICES 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:
SOUL GROWTH PSYCHOLOGICAL SERVICES, PLLC
Provider Other Organization Name Type Code:
3
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:
1982246286
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3760 SLEETH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COMMERCE TWP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48382-1670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-840-5933
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3760 SLEETH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COMMERCE TWP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48382-1670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-840-5933
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/08/2019

Additional Information

Authorized Official

Authorized Official Last Name:
TUPLING
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-840-5933

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1639592785 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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