=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609573112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A SPACE TO REFLECT, THERAPY AND COACHING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2023
-----------------------------------------------------
Last Update Date | 02/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1428 S 4TH ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19147-5928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-225-4428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1428 S 4TH ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19147-5928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-225-4428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | APARNA SAGARAM
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 267-239-6470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------