Healthcare Provider Details

I. General information

NPI: 1518732254
Provider Name (Legal Business Name): SUPPORT SPACE THERAPY AND WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2023
Last Update Date: 11/22/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 HIDDEN MEADOW DR
KELLER TX
76248-1228
US

IV. Provider business mailing address

8528 DAVIS BLVD #134 BOX 139
N RICHLND HLS TX
76182
US

V. Phone/Fax

Practice location:
  • Phone: 203-253-6892
  • Fax:
Mailing address:
  • Phone: 917-914-3951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MARTHA FRANEK-MONTANEZ
Title or Position: OWNER
Credential: LPC
Phone: 203-253-6892