Healthcare Provider Details

I. General information

NPI: 1609782895
Provider Name (Legal Business Name): SOUL WELLNESS LICENSED CLINICAL SOCIAL WORKER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7720 W SUNSET BLVD
WEST HOLLYWOOD CA
90046-3962
US

IV. Provider business mailing address

25 CENTRAL PARK W APT 1U
NEW YORK NY
10023-7214
US

V. Phone/Fax

Practice location:
  • Phone: 516-761-4197
  • Fax:
Mailing address:
  • Phone: 516-761-4197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. SARA GLASS
Title or Position: OWNER
Credential: PHD, LCSW
Phone: 516-761-4197