=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316070345
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPACE COAST COUNSELING CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 06/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 166 CENTER ST STE 239
-----------------------------------------------------
City | CAPE CANAVERAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32920-3717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-267-2288
-----------------------------------------------------
Fax | 866-703-0035
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1284
-----------------------------------------------------
City | CAPE CANAVERAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32920-1284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-267-2288
-----------------------------------------------------
Fax | 866-703-0035
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. LANA LYNN BEASLEY
-----------------------------------------------------
Credential | MA, LMHC
-----------------------------------------------------
Telephone | 321-267-2228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------