MEDICARE: SOUL CARE, 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	101YM0800X	Mental Health Counselor
2	101YP1600X	Pastoral Counselor
3	101YP2500X	Professional Counselor	7710	NC
4	103T00000X	Psychologist
5	1041C0700X	Clinical Social Worker
6	2084P0800X	Psychiatry Physician
7	363A00000X	Physician Assistant
8	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1821320334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUL CARE, PLLC

Provider Business Mailing Address
First Line	:	3695 SUNSET AVE UNIT 8936
Second Line	:
City	:	ROCKY MOUNT
State	:	NC
Zip	:	27804-0286
Country	:	US
Telephone Number	:	980-613-8312
Fax Number	:

Provider Business Practice Location Address
First Line	:	5501 EXECUTIVE CENTER DR STE 215
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-8823
Country	:	US
Telephone Number	:	980-613-8312
Fax Number	:	888-972-4998

Authorized Official
Title or Position	:	CLINICAL DIRECTOR/OWNER
Name	:	CHANTELLE M. JOHNSON
Credential	:	MA, LCMHC-S, LCPC
Telephone Number	:	980-613-8312

Provider Enumeration Date	:	02/08/2010
Last Update Date	:	11/22/2021

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Directions to “SOUL CARE, PLLC ” Practice Location

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