Provider Demographics
NPI:1194477604
Name:SOUL EXPRESSIONS THE COUNSELING AND WELLNESS CAFE PLLC
Entity type:Organization
Organization Name:SOUL EXPRESSIONS THE COUNSELING AND WELLNESS CAFE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOCKLEAR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:910-379-0582
Mailing Address - Street 1:4028 LEMUEL FARM RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28312-9274
Mailing Address - Country:US
Mailing Address - Phone:910-379-0582
Mailing Address - Fax:
Practice Address - Street 1:4028 LEMUEL FARM RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28312-9274
Practice Address - Country:US
Practice Address - Phone:910-379-0582
Practice Address - Fax:910-745-8035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1437704467Medicaid