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General NPI Number Information
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NPI Number | 1699512681
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Entity Type | Organization
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Legal Business Name | SOUL SPARK THERAPY LLC
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Dates
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Enumeration Date | 07/09/2024
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Last Update Date | 07/09/2024
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Provider Practice Location Address
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Address Line | 140 SEPP RD
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City | DEBARY
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State | FL
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Zip | 32713-3914
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Country | US
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Telephone | 407-588-7244
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Fax |
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Provider Business Mailing Address
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Address Line | 1317 EDGEWATER DR # 1732
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City | ORLANDO
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State | FL
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Zip | 32804-6350
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LICENSED MENTAL HEALTH COUNSELOR
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Name | MS. REBECCA RUH
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Credential | LMHC, NCC
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Telephone | 407-588-7244
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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 |
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License Number State |
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