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NPI Code Detail

MEDICARE: SELF SPACE LLC

MEDICARE: SELF SPACE 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
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1568325462
Entity Type Code : Organization
Provider Name (Legal Business Name) : SELF SPACE LLC
Provider Business Mailing Address
First Line : 3330 W IRVINE RD
Second Line :
City : PHOENIX
State : AZ
Zip : 85086-4350
Country : US
Telephone Number : 623-696-8555
Fax Number :
Provider Business Practice Location Address
First Line : 34975 N NORTH VALLEY PKWY STE 152
Second Line :
City : PHOENIX
State : AZ
Zip : 85086-4032
Country : US
Telephone Number : 623-696-8555
Fax Number :
Authorized Official
Title or Position : OWNER/THERAPIST
Name : LISA GEISER
Credential : LPC
Telephone Number : 623-696-8555
Provider Enumeration Date : 12/08/2025
Last Update Date : 12/08/2025

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Directions to “SELF SPACE LLC ” Practice Location

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