Healthcare Provider Details

I. General information

NPI: 1821947516
Provider Name (Legal Business Name): SOULBRIDGE HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2026
Last Update Date: 01/26/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 BROADWAY # 10795
ALBANY NY
12207-2922
US

IV. Provider business mailing address

418 BROADWAY # 10795
ALBANY NY
12207-2922
US

V. Phone/Fax

Practice location:
  • Phone: 410-900-8897
  • Fax: 410-888-7145
Mailing address:
  • Phone: 410-900-8897
  • Fax: 410-888-7145

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
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. FOLASHADE KANIMODO
Title or Position: DIRECTOR
Credential: NURSE PRACTITIONER
Phone: 410-900-8897