Basic Information
Provider Information | |||||||||
NPI: | 1144535394 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COASTAL THERAPY SERVICES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 45 LAFAYETTE RD | ||||||||
Address2: | SUITE 120 | ||||||||
City: | NORTH HAMPTON | ||||||||
State: | NH | ||||||||
PostalCode: | 038622451 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036012752 | ||||||||
FaxNumber: | 6036012752 | ||||||||
Practice Location | |||||||||
Address1: | 989 OCEAN BLVD | ||||||||
Address2: | UNIT 10 | ||||||||
City: | HAMPTON | ||||||||
State: | NH | ||||||||
PostalCode: | 038421453 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036012752 | ||||||||
FaxNumber: | 6036012752 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2010 | ||||||||
LastUpdateDate: | 08/12/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EARWOOD | ||||||||
AuthorizedOfficialFirstName: | KENDRA | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6036012752 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MS, CCC-SLP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1273 | NH | N | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 252Y00000X | 1273 | NH | Y |   | Agencies | Early Intervention Provider Agency |   |
No ID Information.