Provider Demographics
NPI:1508010653
Name:SOUL-FULL SOLUTIONS COUNSELING CENTER, LLC
Entity Type:Organization
Organization Name:SOUL-FULL SOLUTIONS COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:715-805-6111
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:423 GRAND AVE
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-0395
Mailing Address - Country:US
Mailing Address - Phone:715-805-6111
Mailing Address - Fax:715-539-8000
Practice Address - Street 1:423 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-2220
Practice Address - Country:US
Practice Address - Phone:715-805-6111
Practice Address - Fax:715-539-8000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2450101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42253700Medicaid