Healthcare Provider Details

I. General information

NPI: 1205480860
Provider Name (Legal Business Name): MINDSPACE COUNSELING, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 SAM NEWELL RD STE D
MATTHEWS NC
28105-5041
US

IV. Provider business mailing address

PO BOX 78696
CHARLOTTE NC
28271-7038
US

V. Phone/Fax

Practice location:
  • Phone: 704-282-1661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: LIN HU
Title or Position: OWNER
Credential:
Phone: 704-282-1661