Healthcare Provider Details

I. General information

NPI: 1235824582
Provider Name (Legal Business Name): MY HEALING SPACE COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 08/01/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19549 RANDOLPH PL
DENVER CO
80249-8609
US

IV. Provider business mailing address

1155 S HAVANA ST # 11-1150
AURORA CO
80012-4019
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: FANNIE JOHNSON
Title or Position: CERTIFIED ADDICTION SPECIALIST
Credential: CAS
Phone: 720-209-8897