Healthcare Provider Details

I. General information

NPI: 1013725985
Provider Name (Legal Business Name): SOUL JOURNEY FAMILY COUNSELING ORG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2024
Last Update Date: 12/24/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18484 U.S.HWY 18
APPLE VALLEY CA
92307
US

IV. Provider business mailing address

25885 SANTA ROSA RD
APPLE VALLEY CA
92308-0462
US

V. Phone/Fax

Practice location:
  • Phone: 530-443-3828
  • Fax:
Mailing address:
  • Phone: 530-443-3828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: PENNE M LA RUE
Title or Position: CEO
Credential: LMFT
Phone: 530-443-3828