Provider Demographics
NPI:1922606896
Name:SACRED SPACE AN INTEGRATIVE WELLNESS COMMUNITY
Entity Type:Organization
Organization Name:SACRED SPACE AN INTEGRATIVE WELLNESS COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW-R
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HAIRSTON-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-265-2983
Mailing Address - Street 1:405 MARINE LN
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-8208
Mailing Address - Country:US
Mailing Address - Phone:516-265-2983
Mailing Address - Fax:
Practice Address - Street 1:445 LITTLE EAST NECK RD
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-6543
Practice Address - Country:US
Practice Address - Phone:516-265-2983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty