Provider Demographics
NPI:1801783063
Name:SACRED SPACE CHRISTIAN COUNSELING LLC
Entity type:Organization
Organization Name:SACRED SPACE CHRISTIAN COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:LSW, LPCC-S
Authorized Official - Phone:419-438-6465
Mailing Address - Street 1:13361 COUNTY ROAD C2
Mailing Address - Street 2:
Mailing Address - City:HOLGATE
Mailing Address - State:OH
Mailing Address - Zip Code:43527-9628
Mailing Address - Country:US
Mailing Address - Phone:419-438-6465
Mailing Address - Fax:
Practice Address - Street 1:1150 N OTTOKEE ST
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1912
Practice Address - Country:US
Practice Address - Phone:419-330-4141
Practice Address - Fax:419-330-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty