Provider Demographics
NPI:1487194817
Name:ALYSSA BUCHANAN, LLC
Entity Type:Organization
Organization Name:ALYSSA BUCHANAN, LLC
Other - Org Name:SKYLIGHT COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:321-608-0604
Mailing Address - Street 1:630 S WICKHAM RD STE 107
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1429
Mailing Address - Country:US
Mailing Address - Phone:321-608-0604
Mailing Address - Fax:321-608-0604
Practice Address - Street 1:630 S WICKHAM RD STE 107
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1429
Practice Address - Country:US
Practice Address - Phone:321-608-0604
Practice Address - Fax:321-608-0604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-04
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
FLSW123841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014820300Medicaid