Provider Demographics
NPI:1831502152
Name:SOUL SURVIVOR COUNSELING SERVICES PC
Entity type:Organization
Organization Name:SOUL SURVIVOR COUNSELING SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LPCC
Authorized Official - Phone:701-258-2008
Mailing Address - Street 1:1110 COLLEGE DR STE 206
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1207
Mailing Address - Country:US
Mailing Address - Phone:701-258-2008
Mailing Address - Fax:701-223-9114
Practice Address - Street 1:1110 COLLEGE DR STE 206
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1207
Practice Address - Country:US
Practice Address - Phone:701-258-2008
Practice Address - Fax:701-223-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND260-1-1-93-5T101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty