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General NPI Number Information
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NPI Number | 1194695452
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Entity Type | Organization
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Legal Business Name | THE WELLNESS SPACE
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Dates
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Enumeration Date | 11/10/2025
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Last Update Date | 11/10/2025
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Provider Practice Location Address
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Address Line | 1331 UNION AVE STE 1152
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City | MEMPHIS
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State | TN
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Zip | 38104-7509
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Country | US
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Telephone | 901-450-3995
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Fax | 901-450-3995
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Provider Business Mailing Address
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Address Line | 5821 PARK AVE # 171432
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City | MEMPHIS
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State | TN
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Zip | 38119-5134
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Country | US
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Telephone | 901-450-3995
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Fax | 901-450-3995
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Authorized Official
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Title or Position | CEO
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Name | CHANTE SMITH-FASON
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Credential | DNP
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Telephone | 901-450-3995
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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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 | 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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