Provider Demographics
NPI:1700354339
Name:SOUL SPACE THERAPY, LLC
Entity Type:Organization
Organization Name:SOUL SPACE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JANIE
Authorized Official - Middle Name:JANINE
Authorized Official - Last Name:BRYNOLF
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CAC
Authorized Official - Phone:810-845-6090
Mailing Address - Street 1:25078 PURPLE EMPEROR WAY
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33955-6220
Mailing Address - Country:US
Mailing Address - Phone:810-845-6090
Mailing Address - Fax:
Practice Address - Street 1:25078 PURPLE EMPEROR WAY
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33955-6220
Practice Address - Country:US
Practice Address - Phone:810-845-6090
Practice Address - Fax:941-467-1723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-13
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty