Provider Demographics
NPI:1316070345
Name:SPACE COAST COUNSELING CENTER, INC.
Entity type:Organization
Organization Name:SPACE COAST COUNSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LANA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMHC
Authorized Official - Phone:321-267-2228
Mailing Address - Street 1:PO BOX 1284
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-1284
Mailing Address - Country:US
Mailing Address - Phone:321-267-2288
Mailing Address - Fax:866-703-0035
Practice Address - Street 1:166 CENTER ST STE 239
Practice Address - Street 2:
Practice Address - City:CAPE CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920-3717
Practice Address - Country:US
Practice Address - Phone:321-267-2288
Practice Address - Fax:866-703-0035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00493900Medicaid
FL113658100Medicaid
FL313948Medicaid