Basic Information
| Provider Information | |||||||||
| NPI: | 1417394107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRECHT | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | MELINDA | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMHC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2520 SAND MINE RD | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079102941 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2520 SAND MINE RD | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338973402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079102941 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2013 | ||||||||
| LastUpdateDate: | 08/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 13617 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 019386800 | 05 | FL | MEDICAID |