Provider Demographics
NPI:1306615794
Name:SACRED SPACE THERAPY
Entity type:Organization
Organization Name:SACRED SPACE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R, CASAC
Authorized Official - Phone:516-253-1274
Mailing Address - Street 1:26 BERKSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-3710
Mailing Address - Country:US
Mailing Address - Phone:516-253-1274
Mailing Address - Fax:
Practice Address - Street 1:26 BERKSHIRE RD
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3710
Practice Address - Country:US
Practice Address - Phone:516-253-1274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty