Provider Demographics
NPI:1154499804
Name:SOUL FRIENDS, INC
Entity Type:Organization
Organization Name:SOUL FRIENDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:M. KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLL
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:203-679-0849
Mailing Address - Street 1:300 CHURCH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2253
Mailing Address - Country:US
Mailing Address - Phone:203-679-0849
Mailing Address - Fax:
Practice Address - Street 1:300 CHURCH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2253
Practice Address - Country:US
Practice Address - Phone:203-679-0849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0026171041C0700X
CT251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT=========OtherTAX ID