Healthcare Provider Details

I. General information

NPI: 1235961269
Provider Name (Legal Business Name): SOAR THERAPEUTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 E STROOP RD
KETTERING OH
45429-3245
US

IV. Provider business mailing address

68 FORRER BLVD
OAKWOOD OH
45419-3134
US

V. Phone/Fax

Practice location:
  • Phone: 937-701-6262
  • Fax:
Mailing address:
  • Phone: 937-475-3728
  • 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
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PAMELA M WESSEL
Title or Position: OWNER/PROVIDER
Credential: LPCC
Phone: 937-701-6262