Healthcare Provider Details

I. General information

NPI: 1861303679
Provider Name (Legal Business Name): SPACE BOOTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 W STATE ST STE 109
GENEVA IL
60134-2172
US

IV. Provider business mailing address

483 MINNESOTA CIR
CAROL STREAM IL
60188-9217
US

V. Phone/Fax

Practice location:
  • Phone: 872-279-0362
  • Fax:
Mailing address:
  • Phone: 872-279-0362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROBERT GOLDA
Title or Position: FOUNDER
Credential: LCPC
Phone: 872-279-0362