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General NPI Number Information
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NPI Number | 1710153879
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Entity Type | Organization
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Legal Business Name | HEALING SPACE, LLC
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Dates
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Enumeration Date | 05/07/2008
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Last Update Date | 05/07/2008
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Provider Practice Location Address
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Address Line | 1492 PRINCE AVE
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City | ATHENS
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State | GA
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Zip | 30606-2210
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Country | US
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Telephone | 706-614-7341
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5732
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City | ATHENS
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State | GA
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Zip | 30604-5732
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | ALINE ROBOLIN
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Credential |
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Telephone | 706-614-7341
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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 | LPC 002575
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License Number State | GA
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