Provider Demographics
NPI:1215463096
Name:THESPACEBETWEENPSYCHOTHERAPY, LLC
Entity type:Organization
Organization Name:THESPACEBETWEENPSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:DILLENBECK
Authorized Official - Suffix:
Authorized Official - Credentials:MS,NCC, LCPC, CAC-AD
Authorized Official - Phone:443-398-1700
Mailing Address - Street 1:605 N BENTZ ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4982
Mailing Address - Country:US
Mailing Address - Phone:443-398-1700
Mailing Address - Fax:
Practice Address - Street 1:605 N BENTZ ST
Practice Address - Street 2:SUITE 204
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4982
Practice Address - Country:US
Practice Address - Phone:443-398-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6977101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty