Organization
SOUL SAGE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CELESTE LACOMBE NELSON LCSW (SOLE MBR/ OWNER)
(208) 488-8864
Entity
Organization
Contact information
Practice address
1617 W JEFFERSON ST, BOISE, ID 83702-5111
(208) 488-8864
Mailing address
9683 W HOMEWOOD DR, BOISE, ID 83709-5334
(208) 886-0271
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
020200107001043
—
ID
01
—
AETNA
60054
ID
Enumeration date
08/22/2019
Last updated
03/10/2020
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