Healthcare Provider Details

I. General information

NPI: 1174437156
Provider Name (Legal Business Name): SAFE SPACE NEUROBEHAVIORAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 ROBERT ST S STE 202
SAINT PAUL MN
55107-1626
US

IV. Provider business mailing address

220 ROBERT ST S STE 202
SAINT PAUL MN
55107-1626
US

V. Phone/Fax

Practice location:
  • Phone: 612-473-9636
  • Fax: 612-682-5369
Mailing address:
  • Phone: 612-473-9636
  • Fax: 612-682-5369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. MARICRIS PRAGO GOATCHER
Title or Position: FOUNDER & MANAGING DIRECTOR
Credential:
Phone: 612-473-9636