MEDICARE: HEART SPACE MENTAL HEALTH

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1841906740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART SPACE MENTAL HEALTH

Provider Business Mailing Address
First Line	:	5845 CARROLLTON AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-2617
Country	:	US
Telephone Number	:	619-302-3697
Fax Number	:

Provider Business Practice Location Address
First Line	:	17 N 5TH AVE # 1029
Second Line	:
City	:	BEECH GROVE
State	:	IN
Zip	:	46107-1325
Country	:	US
Telephone Number	:	317-210-1175
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	DIANNA STALLINGS
Credential	:	LCSW
Telephone Number	:	619-302-3697

Provider Enumeration Date	:	01/25/2023
Last Update Date	:	01/25/2023

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Directions to “HEART SPACE MENTAL HEALTH ” Practice Location

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