Provider Demographics
NPI:1396239208
Name:COASTAL BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:COASTAL BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAZIA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-671-3788
Mailing Address - Street 1:175 LANCASTER ST STE 218A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2451
Mailing Address - Country:US
Mailing Address - Phone:203-671-3788
Mailing Address - Fax:
Practice Address - Street 1:175 LANCASTER ST STE 218A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2451
Practice Address - Country:US
Practice Address - Phone:203-671-3788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC15872251B00000X, 261QM0801X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1669850376Medicaid
ME1992162390Medicaid