Provider Demographics
NPI:1104053867
Name:CENTER FOR SACRED LIVING
Entity type:Organization
Organization Name:CENTER FOR SACRED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRETEN-GANBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:207-221-0727
Mailing Address - Street 1:69 ANGELL AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5002
Mailing Address - Country:US
Mailing Address - Phone:207-221-0727
Mailing Address - Fax:
Practice Address - Street 1:69 ANGELL AVE
Practice Address - Street 2:APT 1
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5002
Practice Address - Country:US
Practice Address - Phone:207-221-0727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC1171100000X
MELC6487251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty