MEDICARE: SOULS OF SOLACE, 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1649783846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOULS OF SOLACE, LLC

Provider Business Mailing Address
First Line	:	112 N BROADWAY ST
Second Line	:
City	:	CLEVELAND
State	:	OK
Zip	:	74020-3810
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6931 S 66TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74133-1754
Country	:	US
Telephone Number	:	918-221-0705
Fax Number	:

Authorized Official
Title or Position	:	LLC MEMBER/LICENSED THERAPIST
Name	:	MR. DAVID CORDLE JR.
Credential	:	LPC
Telephone Number	:	918-850-6503

Provider Enumeration Date	:	11/09/2017
Last Update Date	:	11/09/2017

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