MEDICARE: SOULSTICE 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	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1447073598
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOULSTICE LLC

Provider Business Mailing Address
First Line	:	10000 NE 74TH ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98662-3802
Country	:	US
Telephone Number	:	503-462-6456
Fax Number	:

Provider Business Practice Location Address
First Line	:	7318 N LEAVITT AVE STE 101
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-4840
Country	:	US
Telephone Number	:	503-462-6456
Fax Number	:

Authorized Official
Title or Position	:	LMT
Name	:	CHAYA PALM
Credential	:
Telephone Number	:	503-462-6456

Provider Enumeration Date	:	11/06/2024
Last Update Date	:	11/06/2024

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Directions to “SOULSTICE LLC ” Practice Location

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