Organization
BRAVE SPACE, LLC
Active
Parent organization
FULL SPECTRUM THERAPY LLC
Organization subpart
Yes
Provider details
NPI number
Legal business name
FULL SPECTRUM THERAPY LLC
Authorized official
SAM SKYE (CEO)
(503) 765-5584
Entity
Organization
Contact information
Practice address
3620 SE POWELL BLVD # 102, PORTLAND, OR 97202-1880
(503) 486-8936
(503) 894-6020
Mailing address
3620 SE POWELL BLVD # 102, PORTLAND, OR 97202-1880
(503) 486-8936
(503) 894-6020
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
C3371
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500717457
—
OR
Enumeration date
08/11/2016
Last updated
05/18/2023
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