Provider Demographics
NPI:1114204625
Name:EXCHANGE CLUB CENTER FOR PREVENTION OF CHILD ABUSE OF THE SPACE COAST
Entity Type:Organization
Organization Name:EXCHANGE CLUB CENTER FOR PREVENTION OF CHILD ABUSE OF THE SPACE COAST
Other - Org Name:YELLOW UMBRELLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALETHEA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KLUVER-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:321-914-9971
Mailing Address - Street 1:4680 LIPSCOMB ST NE
Mailing Address - Street 2:SUITE 10A
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2984
Mailing Address - Country:US
Mailing Address - Phone:321-723-2927
Mailing Address - Fax:321-723-2928
Practice Address - Street 1:4680 LIPSCOMB ST NE
Practice Address - Street 2:SUITE 10A
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2984
Practice Address - Country:US
Practice Address - Phone:321-723-2927
Practice Address - Fax:321-723-2928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-11
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2142251B00000X, 251S00000X, 252Y00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care