| Safe Space Licensed Clinical Social Work, P.c. | |
|
3249 Kingsbridge Ave Bronx NY 10463-5514 | |
| (917) 969-2445 | |
| Not Available |
| Full Name | Safe Space Licensed Clinical Social Work, P.c. |
|---|---|
| Speciality | Social Worker |
| Location | 3249 Kingsbridge Ave, Bronx, New York |
| Authorized Official Name and Position | Michelle Fuentes (OWNER) |
| Authorized Official Contact | 8637387808 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Safe Space Licensed Clinical Social Work, P.c. 8810 Fox Dr Polk City FL 33868-6024 Ph: (863) 738-7808 | Safe Space Licensed Clinical Social Work, P.c. 3249 Kingsbridge Ave Bronx NY 10463-5514 Ph: (917) 969-2445 |
| NPI Number | 1003575358 |
|---|---|
| Provider Enumeration Date | 12/14/2021 |
| Last Update Date | 08/11/2023 |
| Certification Date | 08/11/2023 |
| Medicare PECOS PAC ID | 0840654091 |
|---|---|
| Medicare Enrollment ID | O20230907000211 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1003575358 | NPI | - | NPPES |
| 06578821 | Medicaid | NY |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
| Provider Name | Johan Peguero |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1487907044 PECOS PAC ID: 9830464080 Enrollment ID: I20171013002053 |
| Provider Name | Michelle Fuentes |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1104292473 PECOS PAC ID: 7012321607 Enrollment ID: I20210514001922 |
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