Healthcare Provider Details

I. General information

NPI: 1427965300
Provider Name (Legal Business Name): SACRED SPACE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 OAK ST
REVERE MN
56166-4000
US

IV. Provider business mailing address

125 OAK ST
REVERE MN
56166-4000
US

V. Phone/Fax

Practice location:
  • Phone: 763-213-3933
  • Fax: 320-233-4071
Mailing address:
  • Phone: 763-213-3933
  • Fax: 320-233-4071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. TANYA ANNE LAMBERT
Title or Position: OWNER, PSYCHOTHERAPIST
Credential: LPCC
Phone: 763-213-3933