Healthcare Provider Details

I. General information

NPI: 1649783846
Provider Name (Legal Business Name): SOULS OF SOLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6931 S 66TH EAST AVE
TULSA OK
74133-1754
US

IV. Provider business mailing address

112 N BROADWAY ST
CLEVELAND OK
74020-3810
US

V. Phone/Fax

Practice location:
  • Phone: 918-221-0705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID CORDLE JR.
Title or Position: LLC MEMBER/LICENSED THERAPIST
Credential: LPC
Phone: 918-850-6503