MEDICARE: SOUL SPACE THERAPY, 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	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700354339
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUL SPACE THERAPY, LLC

Provider Business Mailing Address
First Line	:	25078 PURPLE EMPEROR WAY
Second Line	:
City	:	PUNTA GORDA
State	:	FL
Zip	:	33955-6220
Country	:	US
Telephone Number	:	810-845-6090
Fax Number	:

Provider Business Practice Location Address
First Line	:	25078 PURPLE EMPEROR WAY
Second Line	:
City	:	PUNTA GORDA
State	:	FL
Zip	:	33955-6220
Country	:	US
Telephone Number	:	810-845-6090
Fax Number	:	941-467-1723

Authorized Official
Title or Position	:	OWNER/CLINICAL THERAPIST
Name	:	MS. JANIE JANINE BRYNOLF
Credential	:	LCSW, CAC
Telephone Number	:	810-845-6090

Provider Enumeration Date	:	11/13/2018
Last Update Date	:	10/27/2021

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