Provider Demographics
NPI:1235947524
Name:OPEN SPACE MENTAL HEALTH LLC
Entity type:Organization
Organization Name:OPEN SPACE MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:RAE
Authorized Official - Suffix:IV
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:307-690-2938
Mailing Address - Street 1:PO BOX 955
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:WY
Mailing Address - Zip Code:83014-0955
Mailing Address - Country:US
Mailing Address - Phone:307-690-2938
Mailing Address - Fax:
Practice Address - Street 1:530 S HOLMES AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5056
Practice Address - Country:US
Practice Address - Phone:307-690-2938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty