Provider Demographics
NPI:1821545815
Name:SOULSTICE THERAPEUTIC SOLUTIONS, LLC
Entity Type:Organization
Organization Name:SOULSTICE THERAPEUTIC SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:863-773-6573
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873-0577
Mailing Address - Country:US
Mailing Address - Phone:863-773-6573
Mailing Address - Fax:
Practice Address - Street 1:901 W MAIN ST STE 121
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-2532
Practice Address - Country:US
Practice Address - Phone:863-773-6573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13683261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)