Provider Demographics
NPI:1326632415
Name:VIBRANT SOUL LLC
Entity Type:Organization
Organization Name:VIBRANT SOUL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:COSME
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMFT
Authorized Official - Phone:860-994-8556
Mailing Address - Street 1:6 WAY RD STE 217
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06455-1080
Mailing Address - Country:US
Mailing Address - Phone:860-994-8556
Mailing Address - Fax:
Practice Address - Street 1:6 WAY RD STE 217
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06455-1080
Practice Address - Country:US
Practice Address - Phone:860-994-8556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health