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General NPI Number Information
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NPI Number | 1407632334
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Entity Type | Organization
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Legal Business Name | SOUL SPARK COUNSELING, LLC
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Dates
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Enumeration Date | 09/06/2023
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Last Update Date | 09/06/2023
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Provider Practice Location Address
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Address Line | 128 SOUTHWINDS RD
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City | FARMINGTON
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State | AR
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Zip | 72730-8678
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Country | US
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Telephone | 479-222-1156
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1121
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City | PRAIRIE GROVE
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State | AR
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Zip | 72753-1121
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Country | US
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Telephone | 479-222-1156
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Fax |
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Authorized Official
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Title or Position | INCORPORATOR/ORGANIZER
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Name | MS. TESSA RENEE VANDERHORN
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Credential | LAC
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Telephone | 509-306-1102
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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