MEDICARE: SOULFUL GRACE LCSW PLLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1528945607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOULFUL GRACE LCSW PLLC

Provider Business Mailing Address
First Line	:	800 3RD AVE FRNT A1760
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-7649
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 3RD AVE FRNT A1760
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-7649
Country	:	US
Telephone Number	:	201-644-6473
Fax Number	:

Authorized Official
Title or Position	:	MEMBER-MANAGER/OWNER
Name	:	SHANI A GARDNER
Credential	:	LCSW
Telephone Number	:	201-644-6473

Provider Enumeration Date	:	08/19/2025
Last Update Date	:	08/19/2025

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