MEDICARE: EXCHANGE CLUB CENTER FOR PREVENTION OF CHILD ABUSE OF THE SPACE COAST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency	MH2142	FL
2	251B00000X	Case Management Agency	MH2142	FL
3	253Z00000X	In Home Supportive Care Agency	MH2142	FL
4	251S00000X	Community/Behavioral Health Agency	MH2142	FL

General Provider Information

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

Provider Business Mailing Address
First Line	:	4680 LIPSCOMB ST NE
Second Line	:	SUITE 10A
City	:	PALM BAY
State	:	FL
Zip	:	32905-2984
Country	:	US
Telephone Number	:	321-723-2927
Fax Number	:	321-723-2928

Provider Business Practice Location Address
First Line	:	4680 LIPSCOMB ST NE
Second Line	:	SUITE 10A
City	:	PALM BAY
State	:	FL
Zip	:	32905-2984
Country	:	US
Telephone Number	:	321-723-2927
Fax Number	:	321-723-2928

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MS. ALETHEA M KLUVER-WILLIAMS
Credential	:	LCSW
Telephone Number	:	321-914-9971

Provider Enumeration Date	:	11/11/2011
Last Update Date	:	06/15/2015

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