Provider Demographics
NPI:1306608070
Name:SACRED SPACE COLLECTIVE
Entity type:Organization
Organization Name:SACRED SPACE COLLECTIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MIDWIFE, CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOREMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CNM, PMHNP
Authorized Official - Phone:443-553-3082
Mailing Address - Street 1:13359 N HIGHWAY 183 STE 406-620
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-7153
Mailing Address - Country:US
Mailing Address - Phone:443-553-3082
Mailing Address - Fax:512-503-3969
Practice Address - Street 1:13359 N HIGHWAY 183 STE 406-620
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-7153
Practice Address - Country:US
Practice Address - Phone:443-553-3082
Practice Address - Fax:512-503-3969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty