Provider Demographics
NPI:1093309361
Name:SACRED SPACES COUNSELING, LLC
Entity Type:Organization
Organization Name:SACRED SPACES COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:904-885-0724
Mailing Address - Street 1:8825 PERIMETER PARK BLVD STE 601
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1122
Mailing Address - Country:US
Mailing Address - Phone:904-885-0724
Mailing Address - Fax:904-409-3464
Practice Address - Street 1:8825 PERIMETER PARK BLVD STE 601
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1122
Practice Address - Country:US
Practice Address - Phone:904-885-0724
Practice Address - Fax:904-409-3464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty