Provider Demographics
NPI:1962365270
Name:HEART OF SPACE LCSW PLLC
Entity type:Organization
Organization Name:HEART OF SPACE LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:MAXI
Authorized Official - Last Name:EDELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:917-570-5592
Mailing Address - Street 1:107 W VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GHENT
Mailing Address - State:NY
Mailing Address - Zip Code:12075-1618
Mailing Address - Country:US
Mailing Address - Phone:917-579-5592
Mailing Address - Fax:
Practice Address - Street 1:107 W VIEW DR
Practice Address - Street 2:
Practice Address - City:GHENT
Practice Address - State:NY
Practice Address - Zip Code:12075-1618
Practice Address - Country:US
Practice Address - Phone:917-579-5592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-12-04
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty