Provider Demographics
NPI:1356028468
Name:SOUL ALCHEMY LLC
Entity type:Organization
Organization Name:SOUL ALCHEMY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:WALSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:616-633-2170
Mailing Address - Street 1:411 PARIS AVE SE APT 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5401
Mailing Address - Country:US
Mailing Address - Phone:616-633-2170
Mailing Address - Fax:
Practice Address - Street 1:1324 LAKE DR SE STE 4
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1673
Practice Address - Country:US
Practice Address - Phone:616-222-9857
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty