Healthcare Provider Details

I. General information

NPI: 1598302010
Provider Name (Legal Business Name): BODY & SOUL COMMUNITY COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 N 19TH AVE STE 218
PHOENIX AZ
85015-3212
US

IV. Provider business mailing address

5060 N 19TH AVE STE 218
PHOENIX AZ
85015-3212
US

V. Phone/Fax

Practice location:
  • Phone: 480-293-4258
  • Fax:
Mailing address:
  • Phone: 480-293-4258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DAYNA ADAMS
Title or Position: OWNER
Credential:
Phone: 480-293-4258