| Sacred Space Therapy Llc | |
|
2445 Iris Rd Nw Albuquerque NM 87104-3008 | |
| (505) 259-1737 | |
| (505) 448-7925 |
| Full Name | Sacred Space Therapy Llc |
|---|---|
| Speciality | Social Worker |
| Location | 2445 Iris Rd Nw, Albuquerque, New Mexico |
| Authorized Official Name and Position | Gloria J Blea Johnson (OWNER) |
| Authorized Official Contact | 5052591737 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Sacred Space Therapy Llc Po Box 70112 Albuquerque NM 87197-0112 Ph: (505) 259-1737 | Sacred Space Therapy Llc 2445 Iris Rd Nw Albuquerque NM 87104-3008 Ph: (505) 259-1737 |
| NPI Number | 1174205777 |
|---|---|
| Provider Enumeration Date | 08/02/2023 |
| Last Update Date | 04/20/2024 |
| Certification Date | 04/20/2024 |
| Medicare PECOS PAC ID | 0042666984 |
|---|---|
| Medicare Enrollment ID | O20231027002813 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1174205777 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
| Provider Name | Gloria J Blea Johnson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1023106432 PECOS PAC ID: 3779749312 Enrollment ID: I20120725000719 |
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