Basic Information
| Provider Information | |||||||||
| NPI: | 1124520549 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 BROAD AVE | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395013603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288631132 | ||||||||
| FaxNumber: | 2288651700 | ||||||||
| Practice Location | |||||||||
| Address1: | 819B CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395203913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284671881 | ||||||||
| FaxNumber: | 2288651700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2018 | ||||||||
| LastUpdateDate: | 03/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | MCDONALD | ||||||||
| AuthorizedOfficialFirstName: | MANDY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2288631132 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | M9097 | MS | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
No ID Information.