Healthcare Provider Details

I. General information

NPI: 1174205777
Provider Name (Legal Business Name): SACRED SPACE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 04/20/2024
Certification Date: 04/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 IRIS RD NW
ALBUQUERQUE NM
87104-3008
US

IV. Provider business mailing address

PO BOX 70112
ALBUQUERQUE NM
87197-0112
US

V. Phone/Fax

Practice location:
  • Phone: 505-259-1737
  • Fax: 505-448-7925
Mailing address:
  • Phone: 505-259-1737
  • Fax: 505-448-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: GLORIA J BLEA JOHNSON
Title or Position: OWNER
Credential: LCSW, LADAC
Phone: 505-259-1737