Provider Demographics
NPI:1811680390
Name:HEADSPACE & WELLNESS
Entity type:Organization
Organization Name:HEADSPACE & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ESEH
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:804-350-5824
Mailing Address - Street 1:196 ARNOLD PALMER DR
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:NC
Mailing Address - Zip Code:27006-7310
Mailing Address - Country:US
Mailing Address - Phone:804-350-5824
Mailing Address - Fax:
Practice Address - Street 1:2509A LEWISVILLE CLEMMONS RD # 1012
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8712
Practice Address - Country:US
Practice Address - Phone:704-703-3417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-31
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty