Provider Demographics
NPI:1063180057
Name:SAFE SPACE, SLC LLC
Entity type:Organization
Organization Name:SAFE SPACE, SLC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:WITHEE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:310-483-9577
Mailing Address - Street 1:807 E SOUTH TEMPLE STE 200
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1446
Mailing Address - Country:US
Mailing Address - Phone:310-483-9577
Mailing Address - Fax:
Practice Address - Street 1:807 E SOUTH TEMPLE STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1446
Practice Address - Country:US
Practice Address - Phone:310-483-9577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty