Provider Demographics
NPI:1497313282
Name:SOUL RESTORE
Entity Type:Organization
Organization Name:SOUL RESTORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEAN
Authorized Official - Middle Name:GLEN OLIVER
Authorized Official - Last Name:BAXTER
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:202-751-6444
Mailing Address - Street 1:2513 WEST ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-4414
Mailing Address - Country:US
Mailing Address - Phone:202-751-6444
Mailing Address - Fax:
Practice Address - Street 1:1629 K ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-1602
Practice Address - Country:US
Practice Address - Phone:202-751-6444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty