Provider Demographics
NPI:1891206793
Name:PEACE CLUB INC.
Entity Type:Organization
Organization Name:PEACE CLUB INC.
Other - Org Name:PEACE CLUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLSCH
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:321-420-4656
Mailing Address - Street 1:1811 S ORLANDO AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2340
Mailing Address - Country:US
Mailing Address - Phone:321-961-5833
Mailing Address - Fax:
Practice Address - Street 1:1811 S. ORLANDO AVENUE
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931
Practice Address - Country:US
Practice Address - Phone:321-961-5833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13258101YM0800X
FL1000359261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH13258OtherLMHC