Provider Demographics
NPI:1104563378
Name:SANCTUARY PSYCHOTHERAPY SERVICES LLC
Entity type:Organization
Organization Name:SANCTUARY PSYCHOTHERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIBBELS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:845-274-4470
Mailing Address - Street 1:5737 S WATTERSON TRL APT 5
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-1899
Mailing Address - Country:US
Mailing Address - Phone:845-274-4470
Mailing Address - Fax:502-331-6062
Practice Address - Street 1:5737 S WATTERSON TRL APT 5
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-1899
Practice Address - Country:US
Practice Address - Phone:452-744-4708
Practice Address - Fax:502-331-6062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty