MEDICARE: SPACE COAST CENTER FOR SEXUAL HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1659077576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPACE COAST CENTER FOR SEXUAL HEALTH LLC

Provider Business Mailing Address
First Line	:	1314 PORT MALABAR BLVD NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-5238
Country	:	US
Telephone Number	:	321-412-1301
Fax Number	:

Provider Business Practice Location Address
First Line	:	1314 PORT MALABAR BLVD NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-5238
Country	:	US
Telephone Number	:	321-412-1301
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JESSICA SINGH
Credential	:	LCSW
Telephone Number	:	321-412-1301

Provider Enumeration Date	:	02/02/2023
Last Update Date	:	02/02/2023

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