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General NPI Number Information
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NPI Number | 1871161190
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Entity Type | Organization
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Legal Business Name | SOUL-FULL PRESENCE LLC
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Dates
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Enumeration Date | 06/14/2021
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Last Update Date | 06/14/2021
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Provider Practice Location Address
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Address Line | 101 W PARK PL
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City | MIDDLETOWN
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State | DE
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Zip | 19709-1324
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Country | US
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Telephone | 443-617-5152
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Fax | 302-376-6145
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Provider Business Mailing Address
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Address Line | 105 NASHUA CT
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City | BEAR
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State | DE
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Zip | 19701-3324
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Country | US
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Telephone | 144-361-7515
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. JESSICA L. L. DESROSIERS
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Credential | PSY.D.
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Telephone | 443-617-5152
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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