| Soul Space Therapy, Llc | |
|
25078 Purple Emperor Way Punta Gorda FL 33955-6220 | |
| (810) 845-6090 | |
| (941) 467-1723 |
| Full Name | Soul Space Therapy, Llc |
|---|---|
| Speciality | Social Worker |
| Location | 25078 Purple Emperor Way, Punta Gorda, Florida |
| Authorized Official Name and Position | Janie Janine Brynolf (OWNER/CLINICAL THERAPIST) |
| Authorized Official Contact | 8108456090 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Soul Space Therapy, Llc 25078 Purple Emperor Way Punta Gorda FL 33955-6220 Ph: (810) 845-6090 | Soul Space Therapy, Llc 25078 Purple Emperor Way Punta Gorda FL 33955-6220 Ph: (810) 845-6090 |
| NPI Number | 1700354339 |
|---|---|
| Provider Enumeration Date | 11/13/2018 |
| Last Update Date | 10/27/2021 |
| Certification Date | 10/27/2021 |
| Medicare PECOS PAC ID | 7911244470 |
|---|---|
| Medicare Enrollment ID | O20190123000657 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1700354339 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
| Provider Name | Janie J Brynolf |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1104192400 PECOS PAC ID: 2668741489 Enrollment ID: I20190123001059 |
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