Provider Demographics
NPI:1053878108
Name:SOULCIAL SANCTUARY,LLC
Entity type:Organization
Organization Name:SOULCIAL SANCTUARY,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THERAPY/MEDIATION
Authorized Official - Prefix:
Authorized Official - First Name:CHARLETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MASTERS DEGREE
Authorized Official - Phone:407-791-9693
Mailing Address - Street 1:2051 BEACON LANDING CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-4373
Mailing Address - Country:US
Mailing Address - Phone:407-791-9693
Mailing Address - Fax:
Practice Address - Street 1:2051 BEACON LANDING CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-4373
Practice Address - Country:US
Practice Address - Phone:407-791-9693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-25
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty