Healthcare Provider Details

I. General information

NPI: 1750986279
Provider Name (Legal Business Name): SOUL WERK CAFE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4137 SAUK TRL STE 217
RICHTON PARK IL
60471-1253
US

IV. Provider business mailing address

4137 SAUK TRL STE 217
RICHTON PARK IL
60471-1253
US

V. Phone/Fax

Practice location:
  • Phone: 708-580-6042
  • Fax:
Mailing address:
  • Phone: 708-580-6042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. SHANIQUA FORD
Title or Position: OWNER/LEAD THERAPIST
Credential: LCSW
Phone: 773-574-2570