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General NPI Number Information
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NPI Number | 1295520898
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Entity Type | Organization
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Legal Business Name | SPACE COAST HEALTH AND WELLNESS LLC
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Dates
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Enumeration Date | 04/14/2025
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Last Update Date | 04/14/2025
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Provider Practice Location Address
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Address Line | 3040 N WICKHAM RD STE 3
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City | MELBOURNE
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State | FL
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Zip | 32935-2369
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Country | US
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Telephone | 321-425-2424
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Fax | 321-256-5000
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Provider Business Mailing Address
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Address Line | PO BOX 120161
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City | MELBOURNE
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State | FL
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Zip | 32912-0161
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Country | US
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Telephone | 321-425-2424
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Fax | 321-256-5000
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Authorized Official
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Title or Position | CEO/ OWNER
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Name | MRS. ASHLEY MAE FLECK
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Credential | ARNP-BC, PMHNP- BC
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Telephone | 321-425-2424
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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