Provider Demographics
NPI:1679248215
Name:PERSONAL SPACE: SELF CENTERING THERAPY
Entity Type:Organization
Organization Name:PERSONAL SPACE: SELF CENTERING THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYMPHONIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-485-6202
Mailing Address - Street 1:12756 MILLSTREAM DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-1637
Mailing Address - Country:US
Mailing Address - Phone:330-485-6202
Mailing Address - Fax:
Practice Address - Street 1:24100 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5535
Practice Address - Country:US
Practice Address - Phone:330-485-6202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0288471Medicaid