Provider Demographics
NPI:1104465129
Name:ELTON'S SOUL TO SOUL COMPANY
Entity type:Organization
Organization Name:ELTON'S SOUL TO SOUL COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:CARPENTER
Authorized Official - Last Name:ELTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:540-353-2244
Mailing Address - Street 1:6776 HIDDEN WOODS DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-7480
Mailing Address - Country:US
Mailing Address - Phone:540-353-2244
Mailing Address - Fax:
Practice Address - Street 1:3247 ELECTRIC RD STE 1A
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-6448
Practice Address - Country:US
Practice Address - Phone:540-772-0690
Practice Address - Fax:540-772-0692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty