Organization Name: | THE SACRED SELF, LLC |
NPI Number: | 1104227685 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | CHARLEEN K MIELE (OWNER) |
Mailing Address: | 171 Market Sq Suite 102 Newington |
State: | CT US |
Postal Code: | 061112927 |
Phone Number: | 8606148382 |
Fax Number: | 8605615394 |
NPI Enumeration Date: | 09/15/2014 |
NPI Last Update Date: | 09/15/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YP2500X |
License Number: | 002593 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | CT |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Professional |
Taxonomy Definition: |