MEDICARE: SANCTUARY COUNSELING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1083486427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANCTUARY COUNSELING LLC

Provider Business Mailing Address
First Line	:	1716 OAK GROVE RD
Second Line	:
City	:	VAN BUREN
State	:	AR
Zip	:	72956-8629
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6901 DALLAS ST STE A
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5037
Country	:	US
Telephone Number	:	479-210-2146
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JULIANNE PASSEN
Credential	:	LPC
Telephone Number	:	479-670-2143

Provider Enumeration Date	:	10/30/2023
Last Update Date	:	10/30/2023

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