Healthcare Provider Details

I. General information

NPI: 1316070345
Provider Name (Legal Business Name): SPACE COAST COUNSELING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 CENTER ST STE 239
CAPE CANAVERAL FL
32920-3717
US

IV. Provider business mailing address

PO BOX 1284
CAPE CANAVERAL FL
32920-1284
US

V. Phone/Fax

Practice location:
  • Phone: 321-267-2288
  • Fax: 866-703-0035
Mailing address:
  • Phone: 321-267-2288
  • Fax: 866-703-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. LANA LYNN BEASLEY
Title or Position: PRESIDENT
Credential: MA, LMHC
Phone: 321-267-2228