Healthcare Provider Details

I. General information

NPI: 1447025424
Provider Name (Legal Business Name): HEART SPACE HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 W 22ND ST
AUSTIN TX
78705-5104
US

IV. Provider business mailing address

612 W 22ND ST
AUSTIN TX
78705-5104
US

V. Phone/Fax

Practice location:
  • Phone: 737-226-2569
  • Fax:
Mailing address:
  • Phone: 737-226-2569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. ANDREW KALUZA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 254-495-5048