Healthcare Provider Details

I. General information

NPI: 1740937655
Provider Name (Legal Business Name): MINDSPACE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 03/10/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 BRANTLEY HARBOR DR
ST AUGUSTINE FL
32086-1822
US

IV. Provider business mailing address

204 BRANTLEY HARBOR DR
ST AUGUSTINE FL
32086-1822
US

V. Phone/Fax

Practice location:
  • Phone: 203-490-6860
  • Fax: 904-574-4096
Mailing address:
  • Phone: 203-300-3335
  • Fax: 904-574-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DANI M DIMITROVA
Title or Position: OWNER
Credential: LCSW
Phone: 203-300-3335