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General NPI Number Information
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NPI Number | 1942852801
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Entity Type | Organization
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Legal Business Name | BRAVE SPACE COUNSELING & CONSULTING LLC
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Dates
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Enumeration Date | 07/11/2019
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Last Update Date | 07/11/2019
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Provider Practice Location Address
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Address Line | 2950 W CHICAGO AVE
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City | CHICAGO
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State | IL
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Zip | 60622-4375
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Country | US
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Telephone | 312-834-3490
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Fax |
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Provider Business Mailing Address
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Address Line | 433 W HARRISON ST # 8578
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City | CHICAGO
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State | IL
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Zip | 60699-3916
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Country | US
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Telephone | 773-490-7900
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DIANA CASTILLO
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Credential |
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Telephone | 773-490-7900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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