Healthcare Provider Details

I. General information

NPI: 1962365270
Provider Name (Legal Business Name): HEART OF SPACE LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 W VIEW DR
GHENT NY
12075-1618
US

IV. Provider business mailing address

107 W VIEW DR
GHENT NY
12075-1618
US

V. Phone/Fax

Practice location:
  • Phone: 917-579-5592
  • Fax:
Mailing address:
  • Phone: 917-579-5592
  • 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: JILL MAXI EDELSTEIN
Title or Position: OWNER
Credential: LCSW
Phone: 917-570-5592