Provider Demographics
NPI:1033271127
Name:COASTAL SPEECH CENTER INC
Entity Type:Organization
Organization Name:COASTAL SPEECH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:O
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:910-272-9056
Mailing Address - Street 1:210 LIBERTY HILL RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2442
Mailing Address - Country:US
Mailing Address - Phone:910-272-9056
Mailing Address - Fax:910-272-9057
Practice Address - Street 1:210 LIBERTY HILL RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2442
Practice Address - Country:US
Practice Address - Phone:910-272-9056
Practice Address - Fax:910-272-9057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3553235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211989Medicaid
NC28528OtherBCBS