Provider Demographics
NPI:1588917496
Name:SPACE, AMY (MS, LPC)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:
Last Name:SPACE
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8601 ANDERSON MILL RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-4700
Mailing Address - Country:US
Mailing Address - Phone:512-426-2145
Mailing Address - Fax:
Practice Address - Street 1:314 E HIGHLAND MALL BLVD STE 260.14
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-3735
Practice Address - Country:US
Practice Address - Phone:512-426-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66918101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional