MEDICARE: HEALING SPACE COUNSELING SERVICES, LLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1679315535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALING SPACE COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	4963 N MULLIGAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2962
Country	:	US
Telephone Number	:	312-451-1110
Fax Number	:

Provider Business Practice Location Address
First Line	:	4963 N MULLIGAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2962
Country	:	US
Telephone Number	:	312-451-1110
Fax Number	:

Authorized Official
Title or Position	:	BILLER
Name	:	MRS. VANESSA GALVAN
Credential	:	CMRS
Telephone Number	:	832-528-6481

Provider Enumeration Date	:	06/11/2024
Last Update Date	:	06/11/2024

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