Healthcare Provider Details

I. General information

NPI: 1649633785
Provider Name (Legal Business Name): SODAWELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 MIDLAND AVE
BASALT CO
81621-8911
US

IV. Provider business mailing address

PO BOX 4767
BASALT CO
81621-4767
US

V. Phone/Fax

Practice location:
  • Phone: 303-489-0420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0000453
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0012446
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JAMES SODA
Title or Position: OWNER
Credential: M.A, LPC, LAC
Phone: 303-489-0420