=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497467708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A SPACE FOR US COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2022
-----------------------------------------------------
Last Update Date | 04/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 W ORMOND AVE STE 100A
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08002-3051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-920-3848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 914 EDGEMOOR RD
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08034-3940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-920-3848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KEANA REED
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 609-920-3848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------