MEDICARE: YOUR THERAPY S.P.A.C.E. LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	104100000X	Social Worker
2	101Y00000X	Counselor
3	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1265131262
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUR THERAPY S.P.A.C.E. LLC

Provider Business Mailing Address
First Line	:	5113 S HARPER AVE # 2079
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4119
Country	:	US
Telephone Number	:	708-803-2988
Fax Number	:

Provider Business Practice Location Address
First Line	:	5113 S HARPER AVE # 2079
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4119
Country	:	US
Telephone Number	:	708-803-2988
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IMANI ALIMA IBRAHIM
Credential	:	LCSW
Telephone Number	:	630-429-4356

Provider Enumeration Date	:	02/28/2023
Last Update Date	:	02/28/2023

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