Provider Demographics
NPI:1063440022
Name:PREVENT OF BREVARD, INC.
Entity type:Organization
Organization Name:PREVENT OF BREVARD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIMMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-259-7262
Mailing Address - Street 1:1948 PINEAPPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-7609
Mailing Address - Country:US
Mailing Address - Phone:321-259-7262
Mailing Address - Fax:321-259-7198
Practice Address - Street 1:1948 PINEAPPLE AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-7609
Practice Address - Country:US
Practice Address - Phone:321-259-7262
Practice Address - Fax:321-259-7198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL07AD751901251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management