Provider Demographics
NPI:1003623869
Name:INNERSOUL COLLECTIVE LLC
Entity type:Organization
Organization Name:INNERSOUL COLLECTIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CASHONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-799-1809
Mailing Address - Street 1:2005 N PROSPECT AVE # 1079
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2604 HUNTERS POND RUN APT 32
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-2664
Practice Address - Country:US
Practice Address - Phone:773-234-6869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty