Basic Information
| Provider Information | |||||||||
| NPI: | 1417934175 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST MENTAL HEALTH CENTER | ||||||||
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| OtherOrganizationName: | GULF COAST MENTAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1600 BROAD AVE | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395013603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288631132 | ||||||||
| FaxNumber: | 2288651700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2288631132 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | REG13-SO-01 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 320900000X | R-13-1 | MS | N | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | C00120 | 01 | MS | CENTER MEDICARE ID | OTHER | 00018213 | 05 | MS | MEDICAID | QMP000005325798 | 01 | MS | MOLINA MEDICAID | OTHER |