Provider Demographics
NPI:1710479845
Name:AUTHENTIC SPACES COUNSELING, LLC
Entity Type:Organization
Organization Name:AUTHENTIC SPACES COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BYNUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:773-301-3730
Mailing Address - Street 1:5113 FALLS ROAD TER
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-1921
Mailing Address - Country:US
Mailing Address - Phone:773-301-3730
Mailing Address - Fax:
Practice Address - Street 1:4502 SCHENLEY RD # 100A
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2524
Practice Address - Country:US
Practice Address - Phone:443-440-6125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-04
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05089251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health