Provider Demographics
NPI:1417469115
Name:SOUL GROWTH LLC
Entity Type:Organization
Organization Name:SOUL GROWTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:VASA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:307-389-8044
Mailing Address - Street 1:2011 S 2100 E APT 306
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-3176
Mailing Address - Country:US
Mailing Address - Phone:307-389-8044
Mailing Address - Fax:
Practice Address - Street 1:1719 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-1911
Practice Address - Country:US
Practice Address - Phone:307-389-8044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10492016-3501261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)