Healthcare Provider Details

I. General information

NPI: 1568262962
Provider Name (Legal Business Name): SAFE SPACES HEAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2025
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10130 MALLARD CREEK RD STE 300
CHARLOTTE NC
28262-6001
US

IV. Provider business mailing address

117 HALSEY ST
BROOKLYN NY
11216-2103
US

V. Phone/Fax

Practice location:
  • Phone: 347-742-4574
  • Fax:
Mailing address:
  • Phone: 347-742-4574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KONJE BYRON
Title or Position: THERAPIST
Credential:
Phone: 347-742-4574