=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003623869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNERSOUL COLLECTIVE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2024
-----------------------------------------------------
Last Update Date | 01/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2604 HUNTERS POND RUN APT 32
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61820-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-234-6869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2005 N PROSPECT AVE # 1079
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61822-1235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | CASHONNA BERGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-799-1809
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------