Provider Demographics
NPI:1114670478
Name:SOUL DOGS INC GROUP PRACTICE
Entity Type:Organization
Organization Name:SOUL DOGS INC GROUP PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD ACSW LCSW
Authorized Official - Phone:303-250-2785
Mailing Address - Street 1:5005 W 81ST PL UNIT 201
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-4380
Mailing Address - Country:US
Mailing Address - Phone:303-250-2785
Mailing Address - Fax:
Practice Address - Street 1:5005 W 81ST PL UNIT 201
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-4380
Practice Address - Country:US
Practice Address - Phone:303-250-2785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUL DOGS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1427454289Medicaid
CO1851946099Medicaid