Healthcare Provider Details

I. General information

NPI: 1508618455
Provider Name (Legal Business Name): MY HEALING SPACE COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2024
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14211 E 4TH AVE # 3-250
AURORA CO
80011-8736
US

IV. Provider business mailing address

19549 RANDOLPH PL
DENVER CO
80249-8609
US

V. Phone/Fax

Practice location:
  • Phone: 720-209-8897
  • Fax:
Mailing address:
  • Phone: 720-829-4471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FANNIE SHARIEE JOHNSON
Title or Position: OWNER
Credential:
Phone: 720-829-4471