MEDICARE: SACRED SPACE MARRIAGE THERAPY, PROF. CORP

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1831059468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED SPACE MARRIAGE THERAPY, PROF. CORP

Provider Business Mailing Address
First Line	:	31724 CASINO DR
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-4510
Country	:	US
Telephone Number	:	951-219-3255
Fax Number	:

Provider Business Practice Location Address
First Line	:	31526 RAILROAD CANYON RD STE 5
Second Line	:
City	:	CANYON LAKE
State	:	CA
Zip	:	92587-9443
Country	:	US
Telephone Number	:	951-219-3255
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	SHANNON RODRIGUEZ
Credential	:	LMFT
Telephone Number	:	951-219-3255

Provider Enumeration Date	:	11/15/2025
Last Update Date	:	11/15/2025

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