Provider Demographics
NPI:1912405614
Name:YOUR SPACE WELLNESS AND CONSULTING LLC
Entity Type:Organization
Organization Name:YOUR SPACE WELLNESS AND CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAZIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:305-308-2816
Mailing Address - Street 1:3580 MYSTIC POINTE DR
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-2554
Mailing Address - Country:US
Mailing Address - Phone:305-308-2816
Mailing Address - Fax:
Practice Address - Street 1:3580 MYSTIC POINTE DR
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-2554
Practice Address - Country:US
Practice Address - Phone:305-308-2816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-28
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15430305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service