Provider Demographics
NPI:1104227685
Name:THE SACRED SELF, LLC
Entity type:Organization
Organization Name:THE SACRED SELF, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLEEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MIELE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:860-614-8382
Mailing Address - Street 1:171 MARKET SQ
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2927
Mailing Address - Country:US
Mailing Address - Phone:860-614-8382
Mailing Address - Fax:860-561-5394
Practice Address - Street 1:171 MARKET SQ
Practice Address - Street 2:SUITE 102
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2927
Practice Address - Country:US
Practice Address - Phone:860-614-8382
Practice Address - Fax:860-561-5394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002593101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty