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General NPI Number Information
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NPI Number | 1689471708
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Entity Type | Organization
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Legal Business Name | SOUL PRACTICE LICENSED CLINICAL SOCIAL WORKER PC
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Dates
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Enumeration Date | 02/26/2025
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Last Update Date | 02/26/2025
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Provider Practice Location Address
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Address Line | 657 SOUTH MCDONNELL AVE
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City | EAST LOS ANGELES
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State | CA
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Zip | 90022
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Country | US
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Telephone | 800-621-8119
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Fax | 800-621-8119
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Provider Business Mailing Address
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Address Line | 1968 S COAST HWY # 2987
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City | LAGUNA BEACH
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State | CA
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Zip | 92651-3681
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Country | US
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Telephone | 800-621-8119
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Fax | 800-621-8119
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Authorized Official
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Title or Position | OWNER
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Name | KARLA GOMEZ
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Credential | LCSW
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Telephone | 800-621-8119
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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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