Provider Demographics
NPI:1063109528
Name:PROTECTED SPACE THERAPY, PLLC
Entity type:Organization
Organization Name:PROTECTED SPACE THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:980-284-8411
Mailing Address - Street 1:10130 MALLARD CREEK RD STE 306
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-6001
Mailing Address - Country:US
Mailing Address - Phone:980-284-8411
Mailing Address - Fax:
Practice Address - Street 1:10130 MALLARD CREEK RD STE 306
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-6001
Practice Address - Country:US
Practice Address - Phone:980-284-8411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty