Healthcare Provider Details

I. General information

NPI: 1366287112
Provider Name (Legal Business Name): SOULHEALING-PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N MARION ST
OAK PARK IL
60301-1167
US

IV. Provider business mailing address

9200 W MCDOWELL RD UNIT 156
PHOENIX AZ
85037-1189
US

V. Phone/Fax

Practice location:
  • Phone: 708-622-5757
  • Fax:
Mailing address:
  • Phone: 630-788-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KIRSTEN KINGSLEY
Title or Position: COUNSELING PSYCHOLOGIST
Credential: LCPC
Phone: 708-622-5757