Healthcare Provider Details

I. General information

NPI: 1205541000
Provider Name (Legal Business Name): SOUL SPARK COUNSELING & CONSULT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2023
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 BIENVILLE BLVD STE M1
OCEAN SPRINGS MS
39564-3027
US

IV. Provider business mailing address

14205 S COUNTRY HILLS DR
GULFPORT MS
39503-2518
US

V. Phone/Fax

Practice location:
  • Phone: 601-385-5638
  • Fax: 228-366-9056
Mailing address:
  • Phone: 985-774-4076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MARY DODSON
Title or Position: MANAGER
Credential: LMFT
Phone: 985-774-4076