MEDICARE: SACRED SPACE COUNSELING

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1679053268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED SPACE COUNSELING

Provider Business Mailing Address
First Line	:	6010 APPLEWOOD RIDGE CIR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3305
Country	:	US
Telephone Number	:	937-336-6950
Fax Number	:

Provider Business Practice Location Address
First Line	:	1426 N HANCOCK AVE STE 5N
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-2672
Country	:	US
Telephone Number	:	937-336-6950
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SOCIAL WORKER
Name	:	KELLIE MCMASTER
Credential	:
Telephone Number	:	937-336-6950

Provider Enumeration Date	:	08/14/2018
Last Update Date	:	08/14/2018

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