Provider Demographics
NPI:1083101216
Name:GULF COAST MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:GULF COAST MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCDONALD
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 1:15094 COUNTY BARN ROAD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-863-0091
Practice Address - Fax:228-864-2241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM8723320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities