Healthcare Provider Details

I. General information

NPI: 1932929288
Provider Name (Legal Business Name): SOULFUL HEALING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 S WOLFE ST
BALTIMORE MD
21231-3034
US

IV. Provider business mailing address

624 S WOLFE ST
BALTIMORE MD
21231-3034
US

V. Phone/Fax

Practice location:
  • Phone: 240-715-7991
  • Fax:
Mailing address:
  • Phone: 240-715-7991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name: YIANNI MIKALIS
Title or Position: OWNER
Credential: LCPC, LCPAT
Phone: 240-715-7991