Provider Demographics
NPI:1386008753
Name:SPIRIT OF SERVICE COUNSELING & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:SPIRIT OF SERVICE COUNSELING & WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:STATUM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-MHSP
Authorized Official - Phone:901-550-7867
Mailing Address - Street 1:3568 KEARNEY AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-5743
Mailing Address - Country:US
Mailing Address - Phone:901-550-7867
Mailing Address - Fax:901-529-7139
Practice Address - Street 1:3568 KEARNEY AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-5743
Practice Address - Country:US
Practice Address - Phone:901-550-7867
Practice Address - Fax:901-529-7139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000002198305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service