Provider Demographics
NPI:1417737636
Name:HEAD-SPACE MENTAL HEALTH CORP
Entity Type:Organization
Organization Name:HEAD-SPACE MENTAL HEALTH CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-884-0651
Mailing Address - Street 1:201 BOYD ST
Mailing Address - Street 2:
Mailing Address - City:PEPIN
Mailing Address - State:WI
Mailing Address - Zip Code:54759-9706
Mailing Address - Country:US
Mailing Address - Phone:507-884-0651
Mailing Address - Fax:
Practice Address - Street 1:318 1ST AVE SW FL 1
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-3310
Practice Address - Country:US
Practice Address - Phone:507-884-0651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty