MEDICARE: SAFE SPACE, SLC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1063180057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAFE SPACE, SLC LLC

Provider Business Mailing Address
First Line	:	807 E SOUTH TEMPLE STE 200
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1446
Country	:	US
Telephone Number	:	310-483-9577
Fax Number	:

Provider Business Practice Location Address
First Line	:	807 E SOUTH TEMPLE STE 200
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1446
Country	:	US
Telephone Number	:	310-483-9577
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CLINICAL DIRECTOR
Name	:	MRS. JESSICA LEIGH WITHEE
Credential	:	LCSW
Telephone Number	:	310-483-9577

Provider Enumeration Date	:	09/02/2021
Last Update Date	:	09/02/2021

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