Provider Demographics
NPI:1639718208
Name:SANCTUARY WELLNESS AND EDUCATION, LLC.
Entity Type:Organization
Organization Name:SANCTUARY WELLNESS AND EDUCATION, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED SCHOOL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHAQUITA
Authorized Official - Middle Name:RENETTE
Authorized Official - Last Name:NIAMKE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYS, LSPSY
Authorized Official - Phone:216-273-9933
Mailing Address - Street 1:2260 WARRENSVILLE CENTER RD STE 211
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3146
Mailing Address - Country:US
Mailing Address - Phone:216-273-9933
Mailing Address - Fax:
Practice Address - Street 1:2260 WARRENSVILLE CENTER RD STE 211
Practice Address - Street 2:
Practice Address - City:UNIVERSITY HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-3146
Practice Address - Country:US
Practice Address - Phone:216-273-9933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0248411Medicaid