Provider Demographics
NPI:1578137980
Name:SOLACE COUNSELING, LLC
Entity Type:Organization
Organization Name:SOLACE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-458-4170
Mailing Address - Street 1:725 JENSEN GROVE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1636
Mailing Address - Country:US
Mailing Address - Phone:208-274-4565
Mailing Address - Fax:208-550-3287
Practice Address - Street 1:725 JENSEN GROVE DR STE 4
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1636
Practice Address - Country:US
Practice Address - Phone:208-274-4565
Practice Address - Fax:208-550-3287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health