Provider Demographics
NPI:1982818399
Name:SOUL SHINE CHILDREN'S TREATMENT SERVICES, INC.
Entity Type:Organization
Organization Name:SOUL SHINE CHILDREN'S TREATMENT SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESHIA
Authorized Official - Middle Name:ROGERS
Authorized Official - Last Name:DEESE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:910-536-6094
Mailing Address - Street 1:PO BOX 1546
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-1546
Mailing Address - Country:US
Mailing Address - Phone:910-536-6094
Mailing Address - Fax:910-843-9728
Practice Address - Street 1:218 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:RED SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28377-1308
Practice Address - Country:US
Practice Address - Phone:910-536-6094
Practice Address - Fax:910-843-9728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-21969101YA0400X
NCC0051751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106174Medicaid