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General NPI Number Information
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NPI Number | 1871026674
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Entity Type | Organization
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Legal Business Name | SOUL SURGERY LLC
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Dates
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Enumeration Date | 04/07/2017
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Last Update Date | 01/31/2020
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Provider Practice Location Address
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Address Line | 14362 N. FRANK LLOYD WRIGHT #B111
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City | SCOTTSDALE
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State | AZ
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Zip | 85260
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Country | US
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Telephone | 480-912-3105
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Fax | 480-912-3106
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Provider Business Mailing Address
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Address Line | 14362 N. FRANK LLOYD WRIGHT #B111
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City | SCOTTSDALE
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State | AZ
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Zip | 85260
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Country | US
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Telephone | 480-912-3105
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Fax | 480-912-3106
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Authorized Official
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Title or Position | BILLING COMPLIANCE OFFICER
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Name | REGINA SHAKESPEARE
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Credential |
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Telephone | 928-554-5633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | OTC7755
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | OTC8541
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License Number State | AZ
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Taxonomy #4
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 364SP0809X
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Taxonomy Name | Adult Psychiatric/Mental Health Clinical Nurse Specialist
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License Number | OTC7755
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License Number State | AZ
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Taxonomy #6
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Taxonomy Code | 364SP0809X
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Taxonomy Name | Adult Psychiatric/Mental Health Clinical Nurse Specialist
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License Number |
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License Number State |
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