Provider Demographics
NPI:1083287924
Name:SOULRECONSTRUCT PSYCHOTHERAPY
Entity Type:Organization
Organization Name:SOULRECONSTRUCT PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LIC CLINI COUN
Authorized Official - Prefix:
Authorized Official - First Name:SIERRIA
Authorized Official - Middle Name:CHANNING
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:615-424-2761
Mailing Address - Street 1:1136 S DELANO CT W STE B201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3734
Mailing Address - Country:US
Mailing Address - Phone:312-476-9682
Mailing Address - Fax:
Practice Address - Street 1:1136 S DELANO CT W STE B201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3734
Practice Address - Country:US
Practice Address - Phone:312-476-9682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty