Provider Demographics
NPI:1043996986
Name:COASTLINE NEUROPSYCHIATRIC
Entity Type:Organization
Organization Name:COASTLINE NEUROPSYCHIATRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:GROOM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:850-341-4896
Mailing Address - Street 1:304 W GADSDEN ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501
Mailing Address - Country:US
Mailing Address - Phone:850-341-4896
Mailing Address - Fax:850-433-1996
Practice Address - Street 1:890 S PALAFOX ST SUITE 300-L
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502
Practice Address - Country:US
Practice Address - Phone:850-341-4896
Practice Address - Fax:850-433-1996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-26
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty