1750007886 NPI number — SPACE COAST BEHAVIOR ANALYSIS LLC

Table of content: CAROLINE JOY ERICKSON LMHC (NPI 1841374121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750007886 NPI number — SPACE COAST BEHAVIOR ANALYSIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPACE COAST BEHAVIOR ANALYSIS 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:
1750007886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
915 LYTTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32934-9015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-313-4804
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2226 SARNO RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32935-3087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-313-4804
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2022

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
TINA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
321-313-4804

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117441300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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