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General NPI Number Information
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NPI Number | 1477959807
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Entity Type | Organization
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Legal Business Name | SELF-SOULSTICE, LLC
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Dates
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Enumeration Date | 11/12/2014
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Last Update Date | 11/12/2014
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Provider Practice Location Address
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Address Line | 114 N COLLEGE ST
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City | STATESBORO
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State | GA
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Zip | 30458-5309
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Country | US
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Telephone | 912-755-7069
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Fax | 912-480-9733
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Provider Business Mailing Address
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Address Line | 111 HAWTHORNE RD
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City | STATESBORO
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State | GA
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Zip | 30458-6003
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Country | US
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Telephone | 912-755-7069
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Fax | 912-480-9733
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Authorized Official
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Title or Position | OWNER
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Name | DR. D DIONNE BATES
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Credential | PHD
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Telephone | 912-755-7069
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC005007
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License Number State | GA
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