Healthcare Provider Details

I. General information

NPI: 1295520898
Provider Name (Legal Business Name): SPACE COAST HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 N WICKHAM RD STE 3
MELBOURNE FL
32935-2369
US

IV. Provider business mailing address

PO BOX 120161
MELBOURNE FL
32912-0161
US

V. Phone/Fax

Practice location:
  • Phone: 321-425-2424
  • Fax: 321-256-5000
Mailing address:
  • Phone: 321-425-2424
  • Fax: 321-256-5000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. ASHLEY MAE FLECK
Title or Position: CEO/ OWNER
Credential: ARNP-BC, PMHNP- BC
Phone: 321-425-2424