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General NPI Number Information
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NPI Number | 1013781509
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Entity Type | Organization
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Legal Business Name | SOUL SURVIVORS LLC
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Dates
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Enumeration Date | 11/14/2023
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Last Update Date | 11/14/2023
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Provider Practice Location Address
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Address Line | 109 MOUNT CARMEL DR
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City | NATCHEZ
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State | MS
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Zip | 39120-2237
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Country | US
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Telephone | 601-807-4715
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Fax |
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Provider Business Mailing Address
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Address Line | 109 MOUNT CARMEL DR
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City | NATCHEZ
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State | MS
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Zip | 39120-2237
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Country | US
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Telephone | 601-807-4715
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | LYVETTA RENEE MICKELL
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Credential |
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Telephone | 601-807-4715
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 174200000X
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Taxonomy Name | Meals Provider
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State |
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