Healthcare Provider Details

I. General information

NPI: 1033772421
Provider Name (Legal Business Name): HOLDING SPACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2019
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24481 DETROIT RD STE 201
WESTLAKE OH
44145-1557
US

IV. Provider business mailing address

24481 DETROIT RD STE 201
WESTLAKE OH
44145-1557
US

V. Phone/Fax

Practice location:
  • Phone: 440-310-6361
  • Fax: 440-625-2592
Mailing address:
  • Phone: 440-310-6361
  • Fax: 440-625-2592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY MANRODT
Title or Position: CLINICAL DIRECTOR, LISW
Credential: LISW-S
Phone: 440-226-6531