MEDICARE: AFFIRMATIVE SPACES PSYCHOLOGICAL SERVICES

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	103TP2701X	Group Psychotherapy Psychologist
2	103TC0700X	Clinical Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1518379106	OTHER		COMMUNITY MENTAL HEALTH

General Provider Information

NPI Number	:	1841837036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFIRMATIVE SPACES PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	82 I ST SE APT 1307
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20003-3793
Country	:	US
Telephone Number	:	678-777-4036
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 G ST NW STE 800
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20005-6705
Country	:	US
Telephone Number	:	202-770-7067
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER AND CLINICAL DIRECTOR
Name	:	DR. ANTOINE L. CROSBY
Credential	:	PHD
Telephone Number	:	202-770-7067

Provider Enumeration Date	:	12/06/2019
Last Update Date	:	04/27/2020

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