Provider Demographics
NPI:1740650019
Name:SPACE TO BREATHE, PLLC
Entity type:Organization
Organization Name:SPACE TO BREATHE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:603-631-4528
Mailing Address - Street 1:105 WEST MAIN STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LITTLETON
Mailing Address - State:NH
Mailing Address - Zip Code:03561
Mailing Address - Country:US
Mailing Address - Phone:603-631-4528
Mailing Address - Fax:888-822-8323
Practice Address - Street 1:105 WEST MAIN STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:LITTLETON
Practice Address - State:NH
Practice Address - Zip Code:03561
Practice Address - Country:US
Practice Address - Phone:603-631-4528
Practice Address - Fax:888-822-8323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1251103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1023091Medicaid
NH3071687Medicaid