Organization
EPIPHANY SOUL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KIM TATUM LCCA (OWNER/EXECUTIVE DIRECTOR)
(254) 412-9073
Entity
Organization
Contact information
Practice address
5900 CLOVER LN, WACO, TX 76710-2809
(254) 412-9073
Mailing address
5900 CLOVER LN, WACO, TX 76710-2809
Taxonomy
Speciality
Code
Description
License number
State
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
—
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
—
—
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
—
—
Other
Enumeration date
10/20/2025
Last updated
11/11/2025
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