Healthcare Provider Details

I. General information

NPI: 1528756228
Provider Name (Legal Business Name): HEART SPACE COUPLES THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 LINDEN AVE
OAK PARK IL
60302-1659
US

IV. Provider business mailing address

514 LINDEN AVE
OAK PARK IL
60302-1659
US

V. Phone/Fax

Practice location:
  • Phone: 312-391-9342
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: AMY MARKLEY
Title or Position: MANAGING MEMBER
Credential: LCSW
Phone: 312-391-9342