Provider Demographics
NPI:1164071213
Name:SPACE TO HEAL COUNSELING AND WELLNESS, PLLC
Entity Type:Organization
Organization Name:SPACE TO HEAL COUNSELING AND WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUCINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LPCA, NCC
Authorized Official - Phone:336-402-4695
Mailing Address - Street 1:317 COLLEGE RD UNIT 304
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-5385
Mailing Address - Country:US
Mailing Address - Phone:336-402-4695
Mailing Address - Fax:
Practice Address - Street 1:713 N EUGENE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1621
Practice Address - Country:US
Practice Address - Phone:336-585-7188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty