Healthcare Provider Details

I. General information

NPI: 1417737636
Provider Name (Legal Business Name): HEAD-SPACE MENTAL HEALTH CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 FIR ST W
MADERA CA
93636-9044
US

IV. Provider business mailing address

201 BOYD ST
PEPIN WI
54759-9706
US

V. Phone/Fax

Practice location:
  • Phone: 507-884-0651
  • Fax:
Mailing address:
  • Phone: 507-884-0651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DENAY KELLY
Title or Position: CEO
Credential:
Phone: 507-884-0651