MEDICARE: SACREDSPACE PSYCHOTHERAPY, 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1235020330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACREDSPACE PSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	4091 DEAN GROVE WAY
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-5880
Country	:	US
Telephone Number	:	770-651-0582
Fax Number	:

Provider Business Practice Location Address
First Line	:	4091 DEAN GROVE WAY
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-5880
Country	:	US
Telephone Number	:	770-651-0582
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER /CEO
Name	:	MELANIE BENTICK
Credential	:	LPC
Telephone Number	:	770-651-0282

Provider Enumeration Date	:	07/15/2025
Last Update Date	:	07/20/2025

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