Provider Demographics
NPI:1588379044
Name:SAFE SPACE THERAPY LLC
Entity type:Organization
Organization Name:SAFE SPACE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMBROSIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ISELY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, ACLC, PMH-C
Authorized Official - Phone:406-209-8279
Mailing Address - Street 1:725 W ALDER ST STE 27
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4026
Mailing Address - Country:US
Mailing Address - Phone:406-209-8279
Mailing Address - Fax:
Practice Address - Street 1:725 W ALDER ST STE 27
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4026
Practice Address - Country:US
Practice Address - Phone:406-209-8279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty