Provider Demographics
NPI:1255885919
Name:BRAVE SPACE, LLC
Entity type:Organization
Organization Name:BRAVE SPACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SKYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-765-5584
Mailing Address - Street 1:3620 SE POWELL BLVD # 102
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1880
Mailing Address - Country:US
Mailing Address - Phone:503-486-8936
Mailing Address - Fax:503-894-6020
Practice Address - Street 1:3620 SE POWELL BLVD # 102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1880
Practice Address - Country:US
Practice Address - Phone:503-486-8936
Practice Address - Fax:503-894-6020
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FULL SPECTRUM THERAPY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-11
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3371251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500717457Medicaid