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General NPI Number Information
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NPI Number | 1407664279
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Entity Type | Organization
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Legal Business Name | SPACE COAST COUNSELING, LLC
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Dates
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Enumeration Date | 12/24/2024
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Last Update Date | 12/24/2024
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Provider Practice Location Address
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Address Line | 1197 ROCKLEDGE BLVD SUITE 1
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City | ROCKLEDGE
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State | FL
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Zip | 32955-2713
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Country | US
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Telephone | 321-693-8618
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Fax |
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Provider Business Mailing Address
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Address Line | 1197 ROCKLEDGE BLVD SUITE 1
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City | ROCKLEDGE
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State | FL
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Zip | 32955-2713
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Country | US
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Telephone | 321-693-8618
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Fax |
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Authorized Official
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Title or Position | OWNER-LICENSED MENTAL HEALTH COUNSE
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Name | KRISTEN M PENA
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Credential | MA, LMHC
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Telephone | 321-693-8618
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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