Provider Demographics
NPI:1578255246
Name:GROWTH SPACE, PLLC
Entity Type:Organization
Organization Name:GROWTH SPACE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC-S
Authorized Official - Prefix:MS
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:915-703-1415
Mailing Address - Street 1:7516 PORTERHOUSE CT
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79911-2244
Mailing Address - Country:US
Mailing Address - Phone:915-227-4550
Mailing Address - Fax:
Practice Address - Street 1:5900 BALCONES DR STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4298
Practice Address - Country:US
Practice Address - Phone:915-703-1415
Practice Address - Fax:915-265-0667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4714040Medicaid
1033322417OtherTYPE 1 NPI