Healthcare Provider Details

I. General information

NPI: 1114204625
Provider Name (Legal Business Name): EXCHANGE CLUB CENTER FOR PREVENTION OF CHILD ABUSE OF THE SPACE COAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2011
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4680 LIPSCOMB ST NE SUITE 10A
PALM BAY FL
32905-2984
US

IV. Provider business mailing address

4680 LIPSCOMB ST NE SUITE 10A
PALM BAY FL
32905-2984
US

V. Phone/Fax

Practice location:
  • Phone: 321-723-2927
  • Fax: 321-723-2928
Mailing address:
  • Phone: 321-723-2927
  • Fax: 321-723-2928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberMH2142
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMH2142
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberMH2142
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberMH2142
License Number StateFL

VIII. Authorized Official

Name: MS. ALETHEA M KLUVER-WILLIAMS
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 321-914-9971