Healthcare Provider Details

I. General information

NPI: 1578124509
Provider Name (Legal Business Name): HEARTSPACE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W BROADWAY STE E
COLUMBIA MO
65203-3842
US

IV. Provider business mailing address

201 W BROADWAY STE E
COLUMBIA MO
65203-3842
US

V. Phone/Fax

Practice location:
  • Phone: 573-214-0436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: CHRIS LAWRENCE
Title or Position: OWNER/OPERATOR
Credential: PHD
Phone: 573-214-0436