Provider Demographics
NPI:1700387768
Name:SOULSHINE COUNSELING AND WELLNESS, LLC
Entity Type:Organization
Organization Name:SOULSHINE COUNSELING AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-470-5433
Mailing Address - Street 1:1310 GOODMAN RD E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9542
Mailing Address - Country:US
Mailing Address - Phone:662-470-5433
Mailing Address - Fax:501-745-2378
Practice Address - Street 1:1310 GOODMAN RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9542
Practice Address - Country:US
Practice Address - Phone:662-470-5433
Practice Address - Fax:501-745-2378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-26
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2143101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05455768Medicaid