Basic Information
Provider Information | |||||||||
NPI: | 1598127771 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GULF COAST MENTAL HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GULF COAST INDUSTRIES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 BROAD AVE | ||||||||
Address2: |   | ||||||||
City: | GULFPORT | ||||||||
State: | MS | ||||||||
PostalCode: | 395013603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2288631132 | ||||||||
FaxNumber: | 2288651700 | ||||||||
Practice Location | |||||||||
Address1: | 1110 42ND AVE | ||||||||
Address2: |   | ||||||||
City: | GULFPORT | ||||||||
State: | MS | ||||||||
PostalCode: | 395012663 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2288682072 | ||||||||
FaxNumber: | 2288682091 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/25/2016 | ||||||||
LastUpdateDate: | 03/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRITCHARD | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | C F O | ||||||||
AuthorizedOfficialTelephone: | 2288631132 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GULF COAST MENTAL HEALTH CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | REG13-PVS-WAC-01 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
ID Information
ID | Type | State | Issuer | Description | 00770456 | 05 | MS |   | MEDICAID |