| Black Space LLC | |
|
22722 29th Drive Southeast Suite 100 Bothell WA 98021 | |
| (929) 445-7277 | |
| Not Available |
| Full Name | Black Space LLC |
|---|---|
| Speciality | Counselor |
| Location | 22722 29th Drive Southeast Suite 100, Bothell, Washington |
| Authorized Official Name and Position | Tamera Gittens (LMHC) |
| Authorized Official Contact | 9294457277 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Black Space LLC 300 Lenora St # 1348 Seattle WA 98121-2411 Ph: (929) 445-7277 | Black Space LLC 22722 29th Drive Southeast Suite 100 Bothell WA 98021 Ph: (929) 445-7277 |
| NPI Number | 1427860022 |
|---|---|
| Provider Enumeration Date | 01/22/2025 |
| Last Update Date | 01/22/2025 |
| Certification Date | 01/06/2025 |
| Medicare PECOS PAC ID | 2668973843 |
|---|---|
| Medicare Enrollment ID | O20250828004897 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1427860022 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (NU) | Primary |
| Provider Name | Nicol Kayla Igoche |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1366110165 PECOS PAC ID: 8224407705 Enrollment ID: I20221205001754 |
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