Healthcare Provider Details

I. General information

NPI: 1952806556
Provider Name (Legal Business Name): SACRED HEALING THERAPEUTIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6144 DEVON ST
PORTAGE MI
49024-2648
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 734-709-2096
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801075829
License Number StateMI

VIII. Authorized Official

Name: MARY BETH HOUPT
Title or Position: CREDENTIALING
Credential:
Phone: 517-676-9788