Provider Demographics
NPI:1134683550
Name:SPACE FOR GRIEF
Entity Type:Organization
Organization Name:SPACE FOR GRIEF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LMHCA
Authorized Official - Phone:412-728-3890
Mailing Address - Street 1:1008 S 117TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98168-2160
Mailing Address - Country:US
Mailing Address - Phone:412-728-3890
Mailing Address - Fax:
Practice Address - Street 1:340 MORRIS AVE S
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2521
Practice Address - Country:US
Practice Address - Phone:206-717-5915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty