=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790501781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SACRED GROUND PSYCHOTHERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2024
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1240 KELLER PKWY STE 205
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-744-1077
-----------------------------------------------------
Fax | 817-744-1077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1240 KELLER PKWY STE 205
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-744-1077
-----------------------------------------------------
Fax | 817-744-1077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-DIRECTOR
-----------------------------------------------------
Name | DR. JONATHAN MARCOTTE
-----------------------------------------------------
Credential | PSY.D., LP
-----------------------------------------------------
Telephone | 480-290-2991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------