MEDICARE: SOULCIAL SANCTUARY,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1053878108
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOULCIAL SANCTUARY,LLC

Provider Business Mailing Address
First Line	:	2051 BEACON LANDING CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-4373
Country	:	US
Telephone Number	:	407-791-9693
Fax Number	:

Provider Business Practice Location Address
First Line	:	2051 BEACON LANDING CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-4373
Country	:	US
Telephone Number	:	407-791-9693
Fax Number	:

Authorized Official
Title or Position	:	THERAPY/MEDIATION
Name	:	CHARLETTE THOMAS
Credential	:	MASTERS DEGREE
Telephone Number	:	407-791-9693

Provider Enumeration Date	:	02/25/2019
Last Update Date	:	03/04/2019

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