MEDICARE: SACRED CONNECTION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1265080691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED CONNECTION

Provider Business Mailing Address
First Line	:	41 STEPHANIE DR
Second Line	:
City	:	BRUCETON MILLS
State	:	WV
Zip	:	26525-7189
Country	:	US
Telephone Number	:	304-790-0481
Fax Number	:

Provider Business Practice Location Address
First Line	:	507 BURROUGHS ST STE 109
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26505-3392
Country	:	US
Telephone Number	:	304-790-0481
Fax Number	:

Authorized Official
Title or Position	:	SOCIAL WORKER
Name	:	SANDRA KAY CORBETT
Credential	:	LICSW
Telephone Number	:	304-790-0481

Provider Enumeration Date	:	08/28/2019
Last Update Date	:	08/28/2019

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Directions to “SACRED CONNECTION ” Practice Location

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