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General NPI Number Information
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NPI Number | 1033772421
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Entity Type | Organization
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Legal Business Name | HOLDING SPACE LLC
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Dates
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Enumeration Date | 04/21/2019
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Last Update Date | 05/04/2022
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Provider Practice Location Address
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Address Line | 24481 DETROIT RD STE 201
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City | WESTLAKE
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State | OH
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Zip | 44145-1557
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Country | US
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Telephone | 440-310-6361
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Fax | 440-625-2592
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Provider Business Mailing Address
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Address Line | 24481 DETROIT RD STE 201
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City | WESTLAKE
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State | OH
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Zip | 44145-1557
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Country | US
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Telephone | 440-310-6361
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Fax | 440-625-2592
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Authorized Official
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Title or Position | CLINICAL DIRECTOR, LISW
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Name | TIFFANY MANRODT
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Credential | LISW-S
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Telephone | 440-226-6531
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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