Provider Demographics
NPI:1871161190
Name:SOUL-FULL PRESENCE LLC
Entity type:Organization
Organization Name:SOUL-FULL PRESENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA L.
Authorized Official - Middle Name:L
Authorized Official - Last Name:DESROSIERS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:443-617-5152
Mailing Address - Street 1:105 NASHUA CT
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-3324
Mailing Address - Country:US
Mailing Address - Phone:144-361-7515
Mailing Address - Fax:
Practice Address - Street 1:101 W PARK PL
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1324
Practice Address - Country:US
Practice Address - Phone:443-617-5152
Practice Address - Fax:302-376-6145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1003096595OtherMEDICARE
DE471526OtherMEDICARE