Provider Demographics
NPI:1295417186
Name:HEADSPACE PARKING LOT PLLC
Entity type:Organization
Organization Name:HEADSPACE PARKING LOT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:CHRYSTAL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:757-323-9104
Mailing Address - Street 1:76 SUND RD
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-9119
Mailing Address - Country:US
Mailing Address - Phone:360-929-0022
Mailing Address - Fax:
Practice Address - Street 1:76 SUND RD
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541-9119
Practice Address - Country:US
Practice Address - Phone:360-929-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty