Provider Demographics
NPI:1790501781
Name:SACRED GROUND PSYCHOTHERAPY, PLLC
Entity type:Organization
Organization Name:SACRED GROUND PSYCHOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:480-290-2991
Mailing Address - Street 1:1240 KELLER PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-1667
Mailing Address - Country:US
Mailing Address - Phone:817-744-1077
Mailing Address - Fax:817-744-1077
Practice Address - Street 1:1240 KELLER PKWY STE 205
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-1667
Practice Address - Country:US
Practice Address - Phone:817-744-1077
Practice Address - Fax:817-744-1077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty