Provider Demographics
NPI:1164135604
Name:SOULFUL SOMATICS LICENSED CLINICAL SOCIAL WORKER PC
Entity Type:Organization
Organization Name:SOULFUL SOMATICS LICENSED CLINICAL SOCIAL WORKER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISRIN
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:FREE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:530-354-0455
Mailing Address - Street 1:4 GOVERNORS LN STE C
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-5514
Mailing Address - Country:US
Mailing Address - Phone:530-531-3459
Mailing Address - Fax:
Practice Address - Street 1:4 GOVERNORS LN STE C
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-5514
Practice Address - Country:US
Practice Address - Phone:530-531-3459
Practice Address - Fax:844-525-7544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA592984Medicaid