Provider Demographics
NPI: | 1134889462 |
---|---|
Name: | PEACEFUL SOUL THERAPY AND COUNSELING SERVICES LLC |
Entity type: | Organization |
Organization Name: | PEACEFUL SOUL THERAPY AND COUNSELING SERVICES LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CRYSTAL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ADAMS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LCSW |
Authorized Official - Phone: | 904-323-1522 |
Mailing Address - Street 1: | 11778 ALEXANDRA DR |
Mailing Address - Street 2: | |
Mailing Address - City: | JACKSONVILLE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32218-8875 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 646-234-5916 |
Mailing Address - Fax: | 904-212-1093 |
Practice Address - Street 1: | 50 N LAURA ST STE 2500 |
Practice Address - Street 2: | |
Practice Address - City: | JACKSONVILLE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32202-3646 |
Practice Address - Country: | US |
Practice Address - Phone: | 904-323-1522 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-12-28 |
Last Update Date: | 2021-12-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |