MEDICARE: A SAFE SPACE COUNSELING 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	101YM0800X	Mental Health Counselor
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center	MH12311	FL
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1417481235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A SAFE SPACE COUNSELING LLC

Provider Business Mailing Address
First Line	:	1250 S US HIGHWAY 17 92 STE 150
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32750-5712
Country	:	US
Telephone Number	:	321-710-5649
Fax Number	:	321-972-5071

Provider Business Practice Location Address
First Line	:	1250 S US HIGHWAY 17 92 STE 150
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32750-5712
Country	:	US
Telephone Number	:	407-272-1715
Fax Number	:	321-972-5071

Authorized Official
Title or Position	:	OWNER
Name	:	DORA LYNN HENDERSON
Credential	:	LMHC
Telephone Number	:	321-710-5649

Provider Enumeration Date	:	04/18/2017
Last Update Date	:	09/06/2024

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