Provider Demographics
NPI:1174238190
Name:GREY SPACE THERAPY, LCSW PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:GREY SPACE THERAPY, LCSW PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:FABIOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PACHECO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:714-749-5554
Mailing Address - Street 1:5744 CREST AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-8634
Mailing Address - Country:US
Mailing Address - Phone:714-749-5554
Mailing Address - Fax:
Practice Address - Street 1:5055 CANYON CREST DR STE 216
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6015
Practice Address - Country:US
Practice Address - Phone:714-749-5554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty