| Brave Space, Llc | |
|
3620 Se Powell Blvd # 102 Portland OR 97202-1880 | |
| (503) 486-8936 | |
| (503) 894-6020 |
| Full Name | Brave Space, Llc |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 3620 Se Powell Blvd # 102, Portland, Oregon |
| Authorized Official Name and Position | Sam Skye (CEO) |
| Authorized Official Contact | 5037655584 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Brave Space, Llc 3620 Se Powell Blvd # 102 Portland OR 97202-1880 Ph: (503) 486-8936 | Brave Space, Llc 3620 Se Powell Blvd # 102 Portland OR 97202-1880 Ph: (503) 486-8936 |
| NPI Number | 1255885919 |
|---|---|
| Provider Enumeration Date | 08/11/2016 |
| Last Update Date | 05/18/2023 |
| Certification Date | 05/18/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1255885919 | NPI | - | NPPES |
| 500717457 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | C3371 (Oregon) | Primary |
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