Provider Demographics
NPI:1750007886
Name:SPACE COAST BEHAVIOR ANALYSIS LLC
Entity type:Organization
Organization Name:SPACE COAST BEHAVIOR ANALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-313-4804
Mailing Address - Street 1:915 LYTTON RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-9015
Mailing Address - Country:US
Mailing Address - Phone:321-313-4804
Mailing Address - Fax:
Practice Address - Street 1:2226 SARNO RD STE 100
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3087
Practice Address - Country:US
Practice Address - Phone:321-313-4804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-19
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty