1912053919 NPI number — FAMILY COUNSELING CENTER OF BREVARD, INC.

Table of content: (NPI 1912053919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912053919 NPI number — FAMILY COUNSELING CENTER OF BREVARD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY COUNSELING CENTER OF BREVARD, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912053919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
840 BREVARD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955-2149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-632-5792
Provider Business Mailing Address Fax Number:
321-632-5796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 BREVARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKLEDGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32955-2149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-632-5792
Provider Business Practice Location Address Fax Number:
321-632-5796
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KOLODZIEJ
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
321-632-5792

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  SW5110 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 060332500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 275862 . This is a "CLINICAL SOCIAL WORKER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 62-40039 . This is a "CLINICAL SOCIAL WORKER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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