Provider Demographics
NPI:1457724205
Name:BRAVE SOUL COUNSELING SERVICES
Entity Type:Organization
Organization Name:BRAVE SOUL COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELLINGSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT
Authorized Official - Phone:612-242-1224
Mailing Address - Street 1:445 BROADWAY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ST PAUL PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55071-1554
Mailing Address - Country:US
Mailing Address - Phone:612-242-1224
Mailing Address - Fax:651-340-2587
Practice Address - Street 1:445 BROADWAY AVE STE A
Practice Address - Street 2:
Practice Address - City:ST PAUL PARK
Practice Address - State:MN
Practice Address - Zip Code:55071-1554
Practice Address - Country:US
Practice Address - Phone:612-242-1224
Practice Address - Fax:651-340-2587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2671106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty