Provider Demographics
NPI:1689471708
Name:SOUL PRACTICE LICENSED CLINICAL SOCIAL WORKER PC
Entity type:Organization
Organization Name:SOUL PRACTICE LICENSED CLINICAL SOCIAL WORKER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:800-621-8119
Mailing Address - Street 1:1968 S COAST HWY # 2987
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3681
Mailing Address - Country:US
Mailing Address - Phone:800-621-8119
Mailing Address - Fax:800-621-8119
Practice Address - Street 1:657 SOUTH MCDONNELL AVE
Practice Address - Street 2:
Practice Address - City:EAST LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022
Practice Address - Country:US
Practice Address - Phone:800-621-8119
Practice Address - Fax:800-621-8119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty