Provider Demographics
NPI:1245063304
Name:EMBODIED PRACTICE, LLC
Entity type:Organization
Organization Name:EMBODIED PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTULLO
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMHC
Authorized Official - Phone:850-390-4213
Mailing Address - Street 1:4300 BAYOU BLVD STE 25B
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2671
Mailing Address - Country:US
Mailing Address - Phone:850-390-4213
Mailing Address - Fax:
Practice Address - Street 1:4300 BAYOU BLVD STE 25B
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2671
Practice Address - Country:US
Practice Address - Phone:850-390-4213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-23
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty