Healthcare Provider Details

I. General information

NPI: 1144159518
Provider Name (Legal Business Name): LIMINAL THERAPY SPACE LICENSED CLINICAL SOCIAL WORKER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 DOVE ST STE 235
NEWPORT BEACH CA
92660-2806
US

IV. Provider business mailing address

19712 MACARTHUR BLVD STE 110
IRVINE CA
92612-2407
US

V. Phone/Fax

Practice location:
  • Phone: 714-882-9112
  • Fax:
Mailing address:
  • Phone: 714-882-9112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MADISON PARK
Title or Position: PSYCHOTHERAPIST/OWNER
Credential: LCSW
Phone: 714-882-9112