Provider Demographics
NPI:1861715773
Name:GULF COAST MENTAL HEALTH CENTER
Entity type:Organization
Organization Name:GULF COAST MENTAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DEBORA
Authorized Official - Middle Name:J
Authorized Official - Last Name:STANOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-863-1132
Mailing Address - Street 1:1600 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-3603
Mailing Address - Country:US
Mailing Address - Phone:228-863-1132
Mailing Address - Fax:228-865-1700
Practice Address - Street 1:1600 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3603
Practice Address - Country:US
Practice Address - Phone:228-863-1132
Practice Address - Fax:228-865-1700
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GULF COAST MENTAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-05
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR13-1103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770456Medicaid