1093223976 NPI number — SACRED SPACE COUNSELING AND WELLNESS LLC

Table of content: MS. MARY MICHELE LACKEY P.A. (NPI 1124272745)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093223976 NPI number — SACRED SPACE COUNSELING AND WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SACRED SPACE COUNSELING AND WELLNESS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093223976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
195 FOWLER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06249-2503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-617-4082
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 LEBANON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOZRAH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06334-1116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-617-4082
Provider Business Practice Location Address Fax Number:
860-617-4082
Provider Enumeration Date:
01/13/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BONITZ-MOORE
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
Authorized Official Title or Position:
ART THERAPIST, OWNER
Authorized Official Telephone Number:
860-617-4082

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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