Basic Information
| Provider Information | |||||||||
| NPI: | 1861715773 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GULF COAST MENTAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GULF COAST INDUSTRIES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 03/05/2010 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STANOVICH | ||||||||
| AuthorizedOfficialFirstName: | DEBORA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2288631132 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GULF COAST MENTAL HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | R13-1 | 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 |