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NPI Code Detail

MEDICARE: SOUL GROWTH LLC

MEDICARE: SOUL GROWTH LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)10492016-3501UT

General Provider Information

NPI Number : 1417469115
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUL GROWTH LLC
Provider Business Mailing Address
First Line : 2011 S 2100 E APT 306
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84108-3176
Country : US
Telephone Number : 307-389-8044
Fax Number :
Provider Business Practice Location Address
First Line : 1719 S MAIN ST
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84115-1911
Country : US
Telephone Number : 307-389-8044
Fax Number :
Authorized Official
Title or Position : MENTAL HEALTH CLINICIAN
Name : MRS. JESSICA L VASA
Credential : LCSW
Telephone Number : 307-389-8044
Provider Enumeration Date : 11/02/2017
Last Update Date : 11/14/2017

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Directions to “SOUL GROWTH LLC ” Practice Location

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