Healthcare Provider Details

I. General information

NPI: 1609632454
Provider Name (Legal Business Name): SOULFUL AWAKENING THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5737 QUAY DR NE
RIO RANCHO NM
87144-5173
US

IV. Provider business mailing address

5737 QUAY DR NE
RIO RANCHO NM
87144-5173
US

V. Phone/Fax

Practice location:
  • Phone: 808-277-2660
  • Fax:
Mailing address:
  • Phone: 808-277-2660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LISA SANCHEZ
Title or Position: OWNER
Credential: LPCC
Phone: 808-277-2660