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General NPI Number Information
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NPI Number | 1205541000
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Entity Type | Organization
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Legal Business Name | SOUL SPARK COUNSELING & CONSULT, LLC
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Dates
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Enumeration Date | 01/17/2023
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Last Update Date | 07/18/2024
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Provider Practice Location Address
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Address Line | 2112 BIENVILLE BLVD STE M1
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City | OCEAN SPRINGS
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State | MS
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Zip | 39564-3027
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Country | US
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Telephone | 601-385-5638
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Fax | 228-366-9056
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Provider Business Mailing Address
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Address Line | 14205 S COUNTRY HILLS DR
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City | GULFPORT
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State | MS
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Zip | 39503-2518
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Country | US
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Telephone | 985-774-4076
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MARY DODSON
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Credential | LMFT
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Telephone | 985-774-4076
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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