Provider Demographics
NPI:1174205777
Name:SACRED SPACE THERAPY LLC
Entity type:Organization
Organization Name:SACRED SPACE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLEA JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LADAC
Authorized Official - Phone:505-259-1737
Mailing Address - Street 1:PO BOX 70112
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87197-0112
Mailing Address - Country:US
Mailing Address - Phone:505-259-1737
Mailing Address - Fax:505-448-7925
Practice Address - Street 1:2445 IRIS RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-3008
Practice Address - Country:US
Practice Address - Phone:505-259-1737
Practice Address - Fax:505-448-7925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-02
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty