Provider Demographics
NPI:1679329486
Name:THERAPY SPACE LLC
Entity type:Organization
Organization Name:THERAPY SPACE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TALIESIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMNER-LONGBOY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:808-481-7283
Mailing Address - Street 1:RR 3 BOX 81766
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RR 3 81766
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778
Practice Address - Country:US
Practice Address - Phone:808-481-7283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-24
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)