=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194477604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUL EXPRESSIONS THE COUNSELING AND WELLNESS CAFE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2022
-----------------------------------------------------
Last Update Date | 01/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4028 LEMUEL FARM RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28312-9274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-379-0582
-----------------------------------------------------
Fax | 910-745-8035
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4028 LEMUEL FARM RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28312-9274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-379-0582
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TONIA MARIE LOCKLEAR
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 910-379-0582
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------