=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972225423
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SACRED SPACE COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2022
-----------------------------------------------------
Last Update Date | 09/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3407 YORK ST
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76309-3720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-475-9411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3407 YORK ST
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76309-3720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-475-9411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER THERAPIST
-----------------------------------------------------
Name | HEATHER CAWTHON
-----------------------------------------------------
Credential | PH.D., LPC-S
-----------------------------------------------------
Telephone | 469-877-3291
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------