Healthcare Provider Details

I. General information

NPI: 1477121028
Provider Name (Legal Business Name): PEACEFUL SOUL THERAPEUTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 ROUTE 38 STE 149C
CHERRY HILL NJ
08002-2953
US

IV. Provider business mailing address

535 ROUTE 38 EAST SUITE 149C
CHERRY HILL NJ
08002-0811
US

V. Phone/Fax

Practice location:
  • Phone: 856-655-6635
  • Fax:
Mailing address:
  • Phone: 856-267-0499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: SHANNON MARTELLO
Title or Position: OWNER
Credential: LCSW LCADC
Phone: 856-267-0499