MEDICARE: WHOLE SOUL COUNSELING A LICENSED CLINICAL SOCIAL WORKER PC

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
1	1041C0700X	Clinical Social Worker	82146	CA
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1700383718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHOLE SOUL COUNSELING A LICENSED CLINICAL SOCIAL WORKER PC

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

Provider Business Practice Location Address
First Line	:	4125 TEMESCAL ST STE A
Second Line	:
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-7558
Country	:	US
Telephone Number	:	916-877-6894
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	LAUREN KRISTINA MAHAKIAN
Credential	:	LCSW
Telephone Number	:	916-877-6894

Provider Enumeration Date	:	04/07/2018
Last Update Date	:	01/12/2022

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