Provider Demographics
NPI:1912053919
Name:FAMILY COUNSELING CENTER OF BREVARD, INC.
Entity Type:Organization
Organization Name:FAMILY COUNSELING CENTER OF BREVARD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLODZIEJ
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, ACSW
Authorized Official - Phone:321-632-5792
Mailing Address - Street 1:840 BREVARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2149
Mailing Address - Country:US
Mailing Address - Phone:321-632-5792
Mailing Address - Fax:321-632-5796
Practice Address - Street 1:840 BREVARD AVE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2149
Practice Address - Country:US
Practice Address - Phone:321-632-5792
Practice Address - Fax:321-632-5796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW5110251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060332500Medicaid
FL275862OtherCLINICAL SOCIAL WORKER
FL62-40039OtherCLINICAL SOCIAL WORKER
FL62-40039OtherCLINICAL SOCIAL WORKER
FL275862OtherCLINICAL SOCIAL WORKER