Provider Demographics
NPI:1417481235
Name:A SAFE SPACE COUNSELING LLC
Entity type:Organization
Organization Name:A SAFE SPACE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DORA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:321-710-5649
Mailing Address - Street 1:1250 S US HIGHWAY 17 92 STE 150
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5712
Mailing Address - Country:US
Mailing Address - Phone:321-710-5649
Mailing Address - Fax:321-972-5071
Practice Address - Street 1:1250 S US HIGHWAY 17 92 STE 150
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5712
Practice Address - Country:US
Practice Address - Phone:407-272-1715
Practice Address - Fax:321-972-5071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 261QM0801X
FLMH12311261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health