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General NPI Number Information
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NPI Number | 1235020330
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Entity Type | Organization
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Legal Business Name | SACREDSPACE PSYCHOTHERAPY, LLC
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Dates
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Enumeration Date | 07/15/2025
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Last Update Date | 07/20/2025
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Provider Practice Location Address
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Address Line | 4091 DEAN GROVE WAY
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City | LOGANVILLE
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State | GA
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Zip | 30052-5880
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Country | US
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Telephone | 770-651-0582
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Fax |
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Provider Business Mailing Address
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Address Line | 4091 DEAN GROVE WAY
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City | LOGANVILLE
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State | GA
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Zip | 30052-5880
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Country | US
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Telephone | 770-651-0582
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Fax |
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Authorized Official
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Title or Position | FOUNDER /CEO
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Name | MELANIE BENTICK
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Credential | LPC
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Telephone | 770-651-0282
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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