=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740928845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREATING SPACE THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2022
-----------------------------------------------------
Last Update Date | 05/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7509 CANTRELL RD STE 205
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72207-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-396-9308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8240 NORA LN
-----------------------------------------------------
City | SHERWOOD
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72120-9693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-521-7989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | HALEIGH KATHLEEN EDWARDS
-----------------------------------------------------
Credential | MS, LAC, NCC
-----------------------------------------------------
Telephone | 918-521-7989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------