Healthcare Provider Details

I. General information

NPI: 1669383592
Provider Name (Legal Business Name): ELEVATION SPACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 S 20TH ST APT U406
RICHMOND VA
23223-7298
US

IV. Provider business mailing address

10 S 20TH ST APT U406
RICHMOND VA
23223-7298
US

V. Phone/Fax

Practice location:
  • Phone: 757-696-3215
  • Fax:
Mailing address:
  • Phone: 757-696-3215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: SHARENA C GOOSUN
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 757-696-3215