Basic Information
| Provider Information | |||||||||
| NPI: | 1902200116 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KALEIDOSCOPE INTERVENTIONS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 E NASA BLVD STE 104 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212654429 | ||||||||
| FaxNumber: | 3217656434 | ||||||||
| Practice Location | |||||||||
| Address1: | 5830 US HIGHWAY 1 STE 104 | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329555704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216099007 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2014 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | FURR | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO AND MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3213726813 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | GRP2008 | 01 | UNITED HEALTHCARE | OTHER | 014022600 | 05 | FL | MEDICAID | 0089A | 01 | BLUE CROSS BLUE SHEILD | OTHER | 4642140 | 01 | CIGNA | OTHER | 4953527 | 01 | AETNA | OTHER | 5670969 | 01 | CIGNA | OTHER | 5670970 | 01 | CIGNA | OTHER | GF43S | 01 | FLORIDA BLUE | OTHER | 017449700 | 05 | FL | MEDICAID |