Soul Space Therapy, LLC

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

Legal business name

SOUL SPACE THERAPY, LLC

Practice address

25078 Purple Emperor Way
Punta Gorda, FL 33955-6220

Phone

(810) 845-6090

Fax

(941) 467-1723

NPI assigned

Nov 13, 2018

Last updated

Oct 27, 2021By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Janie Janine Brynolf, LCSW, CACNPI 1104192400

Title

Owner/Clinical Therapist

Phone

(810) 845-6090

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in FL, MI2 enrollments

Enrollment records 2

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Janie Brynolf, LCSW, CAC

  • Clinical Social Worker
  • Punta Gorda, FL
  • NPI 1104192400

  MI

  Medicare reassignment NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1542067200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635292800000",
    "number": "1700354339",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "25078 PURPLE EMPEROR WAY",
            "city": "PUNTA GORDA",
            "state": "FL",
            "postal_code": "339556220",
            "telephone_number": "810-845-6090"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "25078 PURPLE EMPEROR WAY",
            "city": "PUNTA GORDA",
            "state": "FL",
            "postal_code": "339556220",
            "telephone_number": "810-845-6090",
            "fax_number": "941-467-1723"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1110 Eldon Baker Dr",
            "address_purpose": "LOCATION",
            "city": "Flint",
            "state": "MI",
            "postal_code": "485071923",
            "country_code": "US",
            "telephone_number": "810-625-4955",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "SOUL SPACE THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-11-13",
        "last_updated": "2021-10-27",
        "certification_date": "2021-10-27",
        "status": "A",
        "authorized_official_last_name": "BRYNOLF",
        "authorized_official_first_name": "JANIE",
        "authorized_official_middle_name": "JANINE",
        "authorized_official_title_or_position": "OWNER/CLINICAL THERAPIST",
        "authorized_official_telephone_number": "810-845-6090",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "LCSW, CAC"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Social Worker in Punta Gorda, FL
• Providers in Punta Gorda, FL by specialty
• Clinical Social Worker in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 27, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.