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General NPI Number Information
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NPI Number | 1356998421
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Entity Type | Organization
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Legal Business Name | SOUL SAGE, LLC
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Dates
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Enumeration Date | 08/22/2019
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Last Update Date | 03/10/2020
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Provider Practice Location Address
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Address Line | 1617 W JEFFERSON ST
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City | BOISE
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State | ID
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Zip | 83702-5111
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Country | US
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Telephone | 208-488-8864
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Fax |
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Provider Business Mailing Address
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Address Line | 9683 W HOMEWOOD DR
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City | BOISE
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State | ID
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Zip | 83709-5334
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Country | US
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Telephone | 208-886-0271
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Fax |
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Authorized Official
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Title or Position | SOLE MBR/ OWNER
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Name | CELESTE LACOMBE NELSON
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Credential | LCSW
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Telephone | 208-488-8864
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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