Provider Demographics
NPI:1710744685
Name:SAFE SPACE TOO
Entity Type:Organization
Organization Name:SAFE SPACE TOO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:NASIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAH-JABEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-384-5149
Mailing Address - Street 1:726 S PRESTON ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-2320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:502-384-3447
Practice Address - Street 1:726 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2320
Practice Address - Country:US
Practice Address - Phone:502-384-5149
Practice Address - Fax:502-384-3447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health