Provider Demographics
NPI:1750986279
Name:SOUL WERK CAFE PLLC
Entity type:Organization
Organization Name:SOUL WERK CAFE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LEAD THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANIQUA
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-574-2570
Mailing Address - Street 1:4137 SAUK TRL STE 217
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1253
Mailing Address - Country:US
Mailing Address - Phone:708-580-6042
Mailing Address - Fax:
Practice Address - Street 1:4137 SAUK TRL STE 217
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1253
Practice Address - Country:US
Practice Address - Phone:708-580-6042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty