Provider Demographics
NPI:1366237901
Name:SOVEREIGN SELF, LLC
Entity type:Organization
Organization Name:SOVEREIGN SELF, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LPCC
Authorized Official - Phone:308-778-7020
Mailing Address - Street 1:17970 ROAD 58
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:NE
Mailing Address - Zip Code:69154-5056
Mailing Address - Country:US
Mailing Address - Phone:308-778-7020
Mailing Address - Fax:
Practice Address - Street 1:35 CERRO DEL ALAMO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4250
Practice Address - Country:US
Practice Address - Phone:720-446-6563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty