Provider Demographics
NPI:1912559675
Name:INTELLECTUALSOUL CLINICAL CONSULTING, LLC
Entity Type:Organization
Organization Name:INTELLECTUALSOUL CLINICAL CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRIMARY PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:IDRIS
Authorized Official - Last Name:MAMBAZO
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:334-625-9617
Mailing Address - Street 1:2541 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2124
Mailing Address - Country:US
Mailing Address - Phone:334-207-7657
Mailing Address - Fax:334-323-6747
Practice Address - Street 1:2541 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2124
Practice Address - Country:US
Practice Address - Phone:334-207-7657
Practice Address - Fax:334-323-6747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health