Basic Information
| Provider Information | |||||||||
| NPI: | 1417084260 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GULF COAST TEACHING FAMILY SERVICE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GULF COAST SOCIAL SERVICES, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 EDENBORN AVE | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700011817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048316561 | ||||||||
| FaxNumber: | 5048353156 | ||||||||
| Practice Location | |||||||||
| Address1: | 723 POINT ST | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703604744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858514488 | ||||||||
| FaxNumber: | 9858720985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | WILLIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5048316561 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MPA | ||||||||
| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | RC2576 | LA | N | Agencies | Community/Behavioral Health | 251S00000X | RC10739 | LA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1935158 | 05 | LA | MEDICAID |