Provider Demographics
NPI:1780448878
Name:SOULLY AWARE LLC
Entity type:Organization
Organization Name:SOULLY AWARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TKACIK
Authorized Official - Suffix:
Authorized Official - Credentials:LMT 26808
Authorized Official - Phone:503-740-6343
Mailing Address - Street 1:1733 E POWELL BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8013
Mailing Address - Country:US
Mailing Address - Phone:503-740-6343
Mailing Address - Fax:503-974-3744
Practice Address - Street 1:1733 E POWELL BLVD STE 102
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8013
Practice Address - Country:US
Practice Address - Phone:503-740-6343
Practice Address - Fax:503-974-3744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-08
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty