=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962849133
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUL-RENITY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2013
-----------------------------------------------------
Last Update Date | 05/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 SAINT PAUL ST 2ND FLOOR
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21202-4871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-921-9800
-----------------------------------------------------
Fax | 410-928-4222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 SAINT PAUL ST 2ND FLOOR
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21202-4871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-921-9800
-----------------------------------------------------
Fax | 410-928-4222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MS. KIER MICHELLE JOHNSON
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 410-921-9800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LC2447
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------