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General NPI Number Information
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NPI Number | 1346940491
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Entity Type | Organization
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Legal Business Name | BRAVE SPACE THERAPY INC
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Dates
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Enumeration Date | 03/07/2023
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Last Update Date | 09/07/2025
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Provider Practice Location Address
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Address Line | 2220 MOUNTAIN BLVD STE 240
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City | OAKLAND
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State | CA
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Zip | 94611-2905
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Country | US
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Telephone | 510-500-5470
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Fax |
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Provider Business Mailing Address
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Address Line | 5665 COLLEGE AVE STE 240E
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City | OAKLAND
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State | CA
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Zip | 94618-1647
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Country | US
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Telephone | 510-500-5470
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RONI KHOL
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Credential | PSY.D
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Telephone | 510-500-5470
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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