MEDICARE: SOUL-RENITY, 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	101YP2500X	Professional Counselor	LC2447	MD

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	:	1962849133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUL-RENITY, LLC

Provider Business Mailing Address
First Line	:	1601 SAINT PAUL ST
Second Line	:	2ND FLOOR
City	:	BALTIMORE
State	:	MD
Zip	:	21202-4871
Country	:	US
Telephone Number	:	410-921-9800
Fax Number	:	410-928-4222

Provider Business Practice Location Address
First Line	:	1601 SAINT PAUL ST
Second Line	:	2ND FLOOR
City	:	BALTIMORE
State	:	MD
Zip	:	21202-4871
Country	:	US
Telephone Number	:	410-921-9800
Fax Number	:	410-928-4222

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	MS. KIER MICHELLE JOHNSON
Credential	:	LCPC
Telephone Number	:	410-921-9800

Provider Enumeration Date	:	05/29/2013
Last Update Date	:	05/08/2017

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Directions to “SOUL-RENITY, LLC ” Practice Location

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