Provider Demographics
NPI:1093223976
Name:SACRED SPACE COUNSELING AND WELLNESS LLC
Entity Type:Organization
Organization Name:SACRED SPACE COUNSELING AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ART THERAPIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BONITZ-MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:ATR-BC, LPC, IMH-E
Authorized Official - Phone:860-617-4082
Mailing Address - Street 1:195 FOWLER RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:CT
Mailing Address - Zip Code:06249-2503
Mailing Address - Country:US
Mailing Address - Phone:860-617-4082
Mailing Address - Fax:
Practice Address - Street 1:46 LEBANON RD
Practice Address - Street 2:
Practice Address - City:BOZRAH
Practice Address - State:CT
Practice Address - Zip Code:06334-1116
Practice Address - Country:US
Practice Address - Phone:860-617-4082
Practice Address - Fax:860-617-4082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-13
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty