Healthcare Provider Details

I. General information

NPI: 1295644912
Provider Name (Legal Business Name): SOUL ROOTS THERAPY & BEHAVIORAL HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 HAYWARD RD
HAMDEN CT
06514-3327
US

IV. Provider business mailing address

2335 DIXWELL AVE STE 2
HAMDEN CT
06514-2100
US

V. Phone/Fax

Practice location:
  • Phone: 203-928-7766
  • Fax:
Mailing address:
  • Phone: 203-928-7766
  • 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: KIMBERLY ANN LEAK
Title or Position: MANAGING MEMBER
Credential:
Phone: 203-928-7766