Organization
SOUL SURGERY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
REGINA SHAKESPEARE (BILLING COMPLIANCE OFFICER)
(928) 554-5633
Entity
Organization
Contact information
Practice address
14362 N. FRANK LLOYD WRIGHT, #B111, SCOTTSDALE, AZ 85260
(480) 912-3105
(480) 912-3106
Mailing address
14362 N. FRANK LLOYD WRIGHT, #B111, SCOTTSDALE, AZ 85260
(480) 912-3105
(480) 912-3106
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
OTC7755
AZ
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
251S00000X
Community/Behavioral Health Agency
OTC8541
AZ
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
364SP0809X
Adult Psychiatric/Mental Health Clinical Nurse Specialist
OTC7755
AZ
364SP0809X
Adult Psychiatric/Mental Health Clinical Nurse Specialist
—
—
Other
Enumeration date
04/07/2017
Last updated
01/31/2020
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