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General NPI Number Information
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NPI Number | 1578435103
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Entity Type | Organization
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Legal Business Name | SACRED EARTH HEALING VILLAGE PLLC
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Dates
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Enumeration Date | 09/23/2025
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Last Update Date | 09/25/2025
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Provider Practice Location Address
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Address Line | 1451 S ELM EUGENE ST STE 2308
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City | GREENSBORO
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State | NC
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Zip | 27406-2200
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Country | US
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Telephone | 336-303-8421
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Fax | 336-464-2137
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Provider Business Mailing Address
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Address Line | 1451 S ELM EUGENE ST STE 2308
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City | GREENSBORO
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State | NC
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Zip | 27406-2200
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Country | US
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Telephone | 336-303-8421
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Fax | 336-464-2137
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Authorized Official
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Title or Position | OWNER
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Name | MS. KRYSTIN JHEREL FULLWOOD
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Credential | LCMHC
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Telephone | 336-280-9976
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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