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General NPI Number Information
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NPI Number | 1346645223
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Entity Type | Organization
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Legal Business Name | SOUL JOURNEY THERAPY
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Dates
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Enumeration Date | 11/04/2014
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Last Update Date | 08/31/2016
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Provider Practice Location Address
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Address Line | 167 MAIN ST SUITE 207E
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City | BRATTLEBORO
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State | VT
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Zip | 05301-7128
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Country | US
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Telephone | 802-451-6598
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Fax |
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Provider Business Mailing Address
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Address Line | 167 MAIN ST BOX 17
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City | BRATTLEBORO
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State | VT
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Zip | 05301-7128
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Country | US
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Telephone | 802-451-6598
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Fax |
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Authorized Official
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Title or Position | FOUNDER, THERAPIST
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Name | SUPRIYA SHANTI
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Credential | LICSW
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Telephone | 802-451-6598
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 089.009440
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License Number State | VT
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 089.009440
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License Number State | VT
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