Provider Demographics
NPI:1003575358
Name:SAFE SPACE LICENSED CLINICAL SOCIAL WORK, P.C.
Entity Type:Organization
Organization Name:SAFE SPACE LICENSED CLINICAL SOCIAL WORK, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:863-738-7808
Mailing Address - Street 1:8810 FOX DR
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33868-6024
Mailing Address - Country:US
Mailing Address - Phone:863-738-7808
Mailing Address - Fax:
Practice Address - Street 1:3249 KINGSBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5514
Practice Address - Country:US
Practice Address - Phone:917-969-2445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-14
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06578821Medicaid