=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578046066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOULBRITE CLINICAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2018
-----------------------------------------------------
Last Update Date | 10/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1550 SPRING RD STE 225
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-1389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-403-8735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1550 SPRING RD STE 225
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-1389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-403-8735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. DAVID HENDRICKS
-----------------------------------------------------
Credential | MA, LCPC
-----------------------------------------------------
Telephone | 630-403-8735
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------