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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TM1800XREG13-PVS-WAC-01MSY193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersPsychologistMental Retardation & Developmental Disabilities

ID Information
IDTypeStateIssuerDescription
0077045605MS MEDICAID


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