Provider Demographics
NPI:1154796266
Name:MY OWN SPACE THERAPY
Entity type:Organization
Organization Name:MY OWN SPACE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:A D
Authorized Official - Last Name:KIMBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:770-756-6030
Mailing Address - Street 1:10440 DEERWOOD RD
Mailing Address - Street 2:1218
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-1135
Mailing Address - Country:US
Mailing Address - Phone:770-756-6030
Mailing Address - Fax:
Practice Address - Street 1:10440 DEERWOOD RD
Practice Address - Street 2:1218
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-1135
Practice Address - Country:US
Practice Address - Phone:770-756-6030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW005881104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty