Provider Demographics
NPI:1699512681
Name:SOUL SPARK THERAPY LLC
Entity type:Organization
Organization Name:SOUL SPARK THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUH
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, NCC
Authorized Official - Phone:407-588-7244
Mailing Address - Street 1:1317 EDGEWATER DR # 1732
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 SEPP RD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-3914
Practice Address - Country:US
Practice Address - Phone:407-588-7244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1669236212OtherNPI TYPE 1