Provider Demographics
NPI:1326775883
Name:KICKSTARTING INSPIRATION & NOURISHING GENTLE SOULS LLC
Entity Type:Organization
Organization Name:KICKSTARTING INSPIRATION & NOURISHING GENTLE SOULS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ZAQUES
Authorized Official - Middle Name:JAMONEZ
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-A
Authorized Official - Phone:252-375-0694
Mailing Address - Street 1:7319 MATTHEWS MINT HILL RD STE I
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-7866
Mailing Address - Country:US
Mailing Address - Phone:336-908-9595
Mailing Address - Fax:
Practice Address - Street 1:7319 MATTHEWS MINT HILL RD STE I
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-7866
Practice Address - Country:US
Practice Address - Phone:336-908-9595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
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
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty