MEDICARE: BRAVE SPACE COUNSELING & CONSULTING 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1942852801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAVE SPACE COUNSELING & CONSULTING LLC

Provider Business Mailing Address
First Line	:	433 W HARRISON ST # 8578
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60699-3916
Country	:	US
Telephone Number	:	773-490-7900
Fax Number	:

Provider Business Practice Location Address
First Line	:	2950 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-4375
Country	:	US
Telephone Number	:	312-834-3490
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DIANA CASTILLO
Credential	:
Telephone Number	:	773-490-7900

Provider Enumeration Date	:	07/11/2019
Last Update Date	:	07/11/2019

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