Provider Demographics
NPI:1326303439
Name:SOULQUEST
Entity Type:Organization
Organization Name:SOULQUEST
Other - Org Name:ADHD WICHITA FALLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:GRANBERY
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC
Authorized Official - Phone:940-228-9732
Mailing Address - Street 1:2407 KEMP BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-5353
Mailing Address - Country:US
Mailing Address - Phone:940-228-9732
Mailing Address - Fax:
Practice Address - Street 1:2407 KEMP BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-5353
Practice Address - Country:US
Practice Address - Phone:940-228-9732
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11729101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty