MEDICARE: THE THERAPY SPACE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1578419685
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE THERAPY SPACE PLLC

Provider Business Mailing Address
First Line	:	3328 DRYSDALE CT
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-3217
Country	:	US
Telephone Number	:	217-273-1849
Fax Number	:

Provider Business Practice Location Address
First Line	:	503 E VANDALIA ST
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-1893
Country	:	US
Telephone Number	:	217-273-1849
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	JORDAN BOYER WALTERS
Credential	:	LCSW
Telephone Number	:	217-273-1849

Provider Enumeration Date	:	03/10/2026
Last Update Date	:	03/10/2026

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Directions to “THE THERAPY SPACE PLLC ” Practice Location

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