Provider Demographics
NPI:1215560735
Name:YOUR SPACE THERAPY
Entity Type:Organization
Organization Name:YOUR SPACE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROONEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:480-442-3354
Mailing Address - Street 1:3961 E CHANDLER BLVD STE 111-112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0303
Mailing Address - Country:US
Mailing Address - Phone:480-442-3354
Mailing Address - Fax:
Practice Address - Street 1:3961 E CHANDLER BLVD STE 111-112
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0303
Practice Address - Country:US
Practice Address - Phone:480-442-3354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty