Healthcare Provider Details

I. General information

NPI: 1154499804
Provider Name (Legal Business Name): SOUL FRIENDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CHURCH ST SUITE 105
WALLINGFORD CT
06492-2253
US

IV. Provider business mailing address

300 CHURCH ST SUITE 105
WALLINGFORD CT
06492-2253
US

V. Phone/Fax

Practice location:
  • Phone: 203-679-0849
  • Fax:
Mailing address:
  • Phone: 203-679-0849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002617
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateCT

VIII. Authorized Official

Name: MS. M. KATHRYN NICOLL
Title or Position: PRESIDENT
Credential: MSW
Phone: 203-679-0849