MEDICARE: SACRED LIFE COUNSELING, PLLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1659015352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED LIFE COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	53505 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-1861
Country	:	US
Telephone Number	:	586-580-1752
Fax Number	:

Provider Business Practice Location Address
First Line	:	53505 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-1861
Country	:	US
Telephone Number	:	586-580-1752
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL/OWNER
Name	:	RACHEL SULLIVAN
Credential	:	LPC
Telephone Number	:	586-580-1752

Provider Enumeration Date	:	04/27/2022
Last Update Date	:	04/27/2022

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