Healthcare Provider Details

I. General information

NPI: 1114756343
Provider Name (Legal Business Name): MENDING SPACE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2024
Last Update Date: 07/27/2024
Certification Date: 07/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CHATHAM RD # 5487
SPRINGFIELD IL
62704-4188
US

IV. Provider business mailing address

2501 CHATHAM RD # 5487
SPRINGFIELD IL
62704-4188
US

V. Phone/Fax

Practice location:
  • Phone: 217-303-8379
  • 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: MICHELLE HOOKS
Title or Position: OWNER
Credential: LCSW
Phone: 217-303-8379