Provider Demographics
NPI:1770046120
Name:HEARTSPACE COUNSELING, PLC
Entity Type:Organization
Organization Name:HEARTSPACE COUNSELING, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, RPT-S
Authorized Official - Phone:505-920-6554
Mailing Address - Street 1:2502 BROADWAY AVE SW UPPR UNIT
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1663
Mailing Address - Country:US
Mailing Address - Phone:540-929-1909
Mailing Address - Fax:877-775-8177
Practice Address - Street 1:2502 BROADWAY AVE SW UPPR UNIT
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1663
Practice Address - Country:US
Practice Address - Phone:540-929-1909
Practice Address - Fax:877-775-8177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM03871347Medicaid