Healthcare Provider Details

I. General information

NPI: 1356028468
Provider Name (Legal Business Name): SOUL ALCHEMY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 06/30/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKE DR SE STE 4
GRAND RAPIDS MI
49506-1673
US

IV. Provider business mailing address

411 PARIS AVE SE APT 2
GRAND RAPIDS MI
49503-5401
US

V. Phone/Fax

Practice location:
  • Phone: 616-222-9857
  • Fax:
Mailing address:
  • Phone: 616-633-2170
  • 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: MARK STEVEN WALSTROM
Title or Position: PRACTICE MANAGER
Credential: LPC
Phone: 616-633-2170