Organization
INTELLECTUALSOUL CLINICAL CONSULTING, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. STEPHAN IDRIS MAMBAZO LICSW (OWNER/PRIMARY PROVIDER)
(334) 625-9617
Entity
Organization
Contact information
Practice address
2541 COLLEGE ST, MONTGOMERY, AL 36106-2124
(334) 207-7657
(334) 323-6747
Mailing address
2541 COLLEGE ST, MONTGOMERY, AL 36106-2124
(334) 207-7657
(334) 323-6747
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Enumeration date
07/12/2019
Last updated
03/12/2021
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