MEDICARE: SOULQUEST

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	11729	TX

General Provider Information

NPI Number	:	1326303439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOULQUEST

Provider Business Mailing Address
First Line	:	2407 KEMP BLVD
Second Line	:	SUITE B
City	:	WICHITA FALLS
State	:	TX
Zip	:	76309-5353
Country	:	US
Telephone Number	:	940-228-9732
Fax Number	:

Provider Business Practice Location Address
First Line	:	2407 KEMP BLVD
Second Line	:	SUITE B
City	:	WICHITA FALLS
State	:	TX
Zip	:	76309-5353
Country	:	US
Telephone Number	:	940-228-9732
Fax Number	:

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	MS. ROCHELLE DIANE GRANBERY
Credential	:	M.ED., LPC
Telephone Number	:	940-228-9732

Provider Enumeration Date	:	07/05/2012
Last Update Date	:	07/05/2012

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Directions to “SOULQUEST ” Practice Location

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