Provider Demographics
NPI:1497561088
Name:COMPASSIONATE HEARTSPACE, LLC
Entity type:Organization
Organization Name:COMPASSIONATE HEARTSPACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCGOVERN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-345-8651
Mailing Address - Street 1:312 NOTTINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-4913
Mailing Address - Country:US
Mailing Address - Phone:757-345-8651
Mailing Address - Fax:
Practice Address - Street 1:104 N HENRY ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-4137
Practice Address - Country:US
Practice Address - Phone:757-345-8651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty