Provider Demographics
NPI:1104699693
Name:SACRED SPACES LLC
Entity type:Organization
Organization Name:SACRED SPACES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEKSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MICIC
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-815-6905
Mailing Address - Street 1:7296 W SENTINAL RD
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84081-6072
Mailing Address - Country:US
Mailing Address - Phone:801-815-6905
Mailing Address - Fax:
Practice Address - Street 1:7296 W SENTINAL RD
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84081-6072
Practice Address - Country:US
Practice Address - Phone:801-815-6905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty