Healthcare Provider Details

I. General information

NPI: 1164617007
Provider Name (Legal Business Name): SOULTENDERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 E FOOTHILL BLVD SUITE 102
ARCADIA CA
91006-2361
US

IV. Provider business mailing address

41 E FOOTHILL BLVD SUITE 102
ARCADIA CA
91006-2361
US

V. Phone/Fax

Practice location:
  • Phone: 626-737-6034
  • Fax: 626-737-6034
Mailing address:
  • Phone: 626-701-4249
  • Fax: 626-737-6034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFC38430
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 22818
License Number StateCA

VIII. Authorized Official

Name: DR. WENDY LUDECKE BENCOSME
Title or Position: OWNER
Credential: PH.D., LMFT
Phone: 626-701-4249