Provider Demographics
NPI:1407632334
Name:SOUL SPARK COUNSELING, LLC
Entity Type:Organization
Organization Name:SOUL SPARK COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INCORPORATOR/ORGANIZER
Authorized Official - Prefix:MS
Authorized Official - First Name:TESSA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:VANDERHORN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:509-306-1102
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE GROVE
Mailing Address - State:AR
Mailing Address - Zip Code:72753-1121
Mailing Address - Country:US
Mailing Address - Phone:479-222-1156
Mailing Address - Fax:
Practice Address - Street 1:128 SOUTHWINDS RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-8678
Practice Address - Country:US
Practice Address - Phone:479-222-1156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty