Provider Demographics
NPI:1942852801
Name:BRAVE SPACE COUNSELING & CONSULTING LLC
Entity Type:Organization
Organization Name:BRAVE SPACE COUNSELING & CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-490-7900
Mailing Address - Street 1:433 W HARRISON ST # 8578
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60699-3916
Mailing Address - Country:US
Mailing Address - Phone:773-490-7900
Mailing Address - Fax:
Practice Address - Street 1:2950 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4375
Practice Address - Country:US
Practice Address - Phone:312-834-3490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty