MEDICARE: BRAVE 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
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1811427693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAVE SPACE, LLC

Provider Business Mailing Address
First Line	:	5168 VILLAGE CREEK DR STE 100
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-4447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5168 VILLAGE CREEK DR STE 100
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-4447
Country	:	US
Telephone Number	:	469-215-2890
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	SARAH REES
Credential	:	LPC-S, RPT-S
Telephone Number	:	469-215-2890

Provider Enumeration Date	:	06/14/2017
Last Update Date	:	01/25/2024

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Directions to “BRAVE SPACE, LLC ” Practice Location

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