Provider Demographics
NPI:1134346661
Name:SOLACE, LLC
Entity type:Organization
Organization Name:SOLACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHERBAK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:423-752-5207
Mailing Address - Street 1:3097 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37408-3093
Mailing Address - Country:US
Mailing Address - Phone:423-752-5207
Mailing Address - Fax:423-752-5299
Practice Address - Street 1:3097 BROAD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37408-3093
Practice Address - Country:US
Practice Address - Phone:423-752-5207
Practice Address - Fax:423-752-5299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 261QR0401X
TN10000000074103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4055601OtherBCBS