Provider Demographics
NPI:1366030934
Name:WELL SPACE, LLC
Entity Type:Organization
Organization Name:WELL SPACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATIA
Authorized Official - Middle Name:JASMIN
Authorized Official - Last Name:ROBINSON LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:239-677-6664
Mailing Address - Street 1:3606 14TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33976-2949
Mailing Address - Country:US
Mailing Address - Phone:239-677-6664
Mailing Address - Fax:
Practice Address - Street 1:4206 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-7154
Practice Address - Country:US
Practice Address - Phone:239-677-6664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018998800Medicaid