Provider Demographics
NPI:1679281588
Name:SACRED GROUND INSTITUTE LLC
Entity Type:Organization
Organization Name:SACRED GROUND INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAWANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOLFOLK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-927-0042
Mailing Address - Street 1:140 CAPTAIN THOMAS BLVD STE 211B
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-5951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 CAPTAIN THOMAS BLVD STE 211B
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-5951
Practice Address - Country:US
Practice Address - Phone:203-927-0042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty