# SOUL SANCTUARY, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1003557943
- **Authorized official:** LISA NASHAWATY (PROGRAM DIRECTOR)
- **Authorized official phone:** (617) 690-9020

## Contact information

- **Practice address:** 1519 FOREST AVE, PORTLAND, ME 04103-1805
- **Practice address phone:** (617) 690-9020
- **Mailing address:** 22 REDLON RD, PORTLAND, ME 04102-2218
- **Mailing address phone:** (617) 690-9020

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101YA0400X | Addiction (Substance Use Disorder) Counselor | — | — | Yes |

## Other

- **Enumeration date:** 04/05/2022
- **Last updated:** 04/05/2022