Provider Demographics
NPI:1982348165
Name:YOUR SAFE SPACE
Entity Type:Organization
Organization Name:YOUR SAFE SPACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:301-980-4581
Mailing Address - Street 1:10111 MARTIN LUTHER KING JR HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4225
Mailing Address - Country:US
Mailing Address - Phone:301-459-0708
Mailing Address - Fax:
Practice Address - Street 1:10111 MARTIN LUTHER KING JR HWY STE 103
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4225
Practice Address - Country:US
Practice Address - Phone:301-459-0708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD819022400Medicaid