Provider Demographics
NPI:1578435103
Name:SACRED EARTH HEALING VILLAGE PLLC
Entity type:Organization
Organization Name:SACRED EARTH HEALING VILLAGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KRYSTIN
Authorized Official - Middle Name:JHEREL
Authorized Official - Last Name:FULLWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:336-280-9976
Mailing Address - Street 1:1451 S ELM EUGENE ST STE 2308
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-2200
Mailing Address - Country:US
Mailing Address - Phone:336-303-8421
Mailing Address - Fax:336-464-2137
Practice Address - Street 1:1451 S ELM EUGENE ST STE 2308
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-2200
Practice Address - Country:US
Practice Address - Phone:336-303-8421
Practice Address - Fax:336-464-2137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-23
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty