MEDICARE: SURE SPACE THERAPY, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1558938167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURE SPACE THERAPY, LLC

Provider Business Mailing Address
First Line	:	7333 BROOKCREST DR UNIT 2
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45237-3407
Country	:	US
Telephone Number	:	323-381-0837
Fax Number	:

Provider Business Practice Location Address
First Line	:	7333 BROOKCREST DR UNIT 2
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45237-3407
Country	:	US
Telephone Number	:	323-381-0837
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. KRISTINA MURRAY
Credential	:	LCSW
Telephone Number	:	323-381-0837

Provider Enumeration Date	:	06/10/2021
Last Update Date	:	09/08/2021

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