MEDICARE: SOUL JOURNEY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073273082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUL JOURNEY LLC

Provider Business Mailing Address
First Line	:	8310 CHARLESTON PEAK ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-5168
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8310 CHARLESTON PEAK ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-5168
Country	:	US
Telephone Number	:	702-321-8984
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TRACEE THOMAS
Credential	:
Telephone Number	:	702-321-8984

Provider Enumeration Date	:	12/19/2021
Last Update Date	:	12/19/2021

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Directions to “SOUL JOURNEY LLC ” Practice Location

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