Provider Demographics
NPI:1417759655
Name:SOUL RENEWAL THERAPY LLC
Entity type:Organization
Organization Name:SOUL RENEWAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIENOW PAYCHEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-380-0349
Mailing Address - Street 1:338 LAWTON RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2359
Mailing Address - Country:US
Mailing Address - Phone:605-380-0349
Mailing Address - Fax:
Practice Address - Street 1:338 LAWTON RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2359
Practice Address - Country:US
Practice Address - Phone:605-380-0349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty