Provider Demographics
NPI:1891356119
Name:INNERSPACE CENTER FOR EMOTIONAL HEALTH LLC
Entity Type:Organization
Organization Name:INNERSPACE CENTER FOR EMOTIONAL HEALTH LLC
Other - Org Name:INNERSPACE CENTER FOR EMOTIONAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TIN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERTAUS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:812-772-8289
Mailing Address - Street 1:101 PLAZA EAST BLVD STE 224
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2806
Mailing Address - Country:US
Mailing Address - Phone:812-773-8289
Mailing Address - Fax:812-308-4064
Practice Address - Street 1:101 PLAZA EAST BLVD STE 224
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2806
Practice Address - Country:US
Practice Address - Phone:812-773-8289
Practice Address - Fax:812-308-4064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty