Healthcare Provider Details

I. General information

NPI: 1427860022
Provider Name (Legal Business Name): BLACK SPACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 01/22/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22722 29TH DRIVE SOUTHEAST SUITE 100
BOTHELL WA
98021
US

IV. Provider business mailing address

300 LENORA ST # 1348
SEATTLE WA
98121-2411
US

V. Phone/Fax

Practice location:
  • Phone: 929-445-7277
  • Fax:
Mailing address:
  • Phone: 929-445-7277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TAMERA GITTENS
Title or Position: LMHC
Credential:
Phone: 929-445-7277