=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750872941
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING SPACE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2018
-----------------------------------------------------
Last Update Date | 05/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HEALING SPACE LLC 206 B ALLEGHENY STREET
-----------------------------------------------------
City | HOLLIDAYSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-937-8872
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 708 BEAUMONT DR
-----------------------------------------------------
City | ALTOONA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16602-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-937-8872
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HEATHER RENEE ATTIA
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 814-937-8872
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC005266
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------