Healthcare Provider Details

I. General information

NPI: 1700387768
Provider Name (Legal Business Name): SOULSHINE COUNSELING AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 GOODMAN RD E
SOUTHAVEN MS
38671-9542
US

IV. Provider business mailing address

1310 GOODMAN RD E
SOUTHAVEN MS
38671-9542
US

V. Phone/Fax

Practice location:
  • Phone: 662-470-5433
  • Fax: 501-745-2378
Mailing address:
  • Phone: 662-470-5433
  • Fax: 501-745-2378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2143
License Number StateMS

VIII. Authorized Official

Name: MARY ELIZABETH FOX
Title or Position: OWNER
Credential:
Phone: 662-470-5433