Provider Demographics
NPI:1578375903
Name:HEADSPACE MENTAL WELLNESS CLUB LLC
Entity type:Organization
Organization Name:HEADSPACE MENTAL WELLNESS CLUB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUNARI
Authorized Official - Middle Name:
Authorized Official - Last Name:CODY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:229-375-1673
Mailing Address - Street 1:527 COTTONWOOD CV
Mailing Address - Street 2:
Mailing Address - City:HAHIRA
Mailing Address - State:GA
Mailing Address - Zip Code:31632-1591
Mailing Address - Country:US
Mailing Address - Phone:229-375-1673
Mailing Address - Fax:
Practice Address - Street 1:527 COTTONWOOD CV
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632-1591
Practice Address - Country:US
Practice Address - Phone:229-375-1673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty