1538524194 NPI number — BEACHSIDE COUNSELING AND WELLNESS, LLC

Table of content: (NPI 1538524194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538524194 NPI number — BEACHSIDE COUNSELING AND WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACHSIDE COUNSELING AND WELLNESS, LLC
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:
1538524194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2105 S RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32951-2929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-327-3793
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 4TH AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
INDIALANTIC
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32903-3112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-327-3793
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LAUER
Authorized Official First Name:
LUCY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
321-327-3793

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  MH9141 , 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: 1336264902 . This is a "NPPES" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com