Provider Demographics
NPI:1679160063
Name:SACRED SPACE, LLC
Entity type:Organization
Organization Name:SACRED SPACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:ARIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MESA
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW RYT
Authorized Official - Phone:202-265-1000
Mailing Address - Street 1:325 ELLINGTON BLVD # 171
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-4591
Mailing Address - Country:US
Mailing Address - Phone:202-567-7726
Mailing Address - Fax:
Practice Address - Street 1:19310 SHERWOOD GREEN WAY
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879
Practice Address - Country:US
Practice Address - Phone:202-567-7726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty