Healthcare Provider Details

I. General information

NPI: 1942933130
Provider Name (Legal Business Name): OPEN SPACE PSYCHOTHERAPY COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2904 W SUNSET BLVD STE 6
LOS ANGELES CA
90026-7308
US

IV. Provider business mailing address

2904 W SUNSET BLVD STE 6
LOS ANGELES CA
90026-7308
US

V. Phone/Fax

Practice location:
  • Phone: 424-283-1845
  • Fax:
Mailing address:
  • Phone: 213-534-7013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: RENAE JOHNSON
Title or Position: CEO/FOUNDER
Credential: LPCC
Phone: 213-534-7013