Provider Demographics
NPI:1366105884
Name:SHARED SPACE LLC
Entity type:Organization
Organization Name:SHARED SPACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATCH-SABLAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:317-361-0962
Mailing Address - Street 1:5308 E 71ST ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3894
Mailing Address - Country:US
Mailing Address - Phone:317-361-0962
Mailing Address - Fax:
Practice Address - Street 1:942 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-2602
Practice Address - Country:US
Practice Address - Phone:317-361-0962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-21
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300047038Medicaid