Provider Demographics
NPI:1093242091
Name:COASTAL NEUROPSYCHOLOGY SERVICES, P.A.
Entity Type:Organization
Organization Name:COASTAL NEUROPSYCHOLOGY SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:CHASMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-997-4723
Mailing Address - Street 1:PO BOX 2520
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29465-2520
Mailing Address - Country:US
Mailing Address - Phone:860-997-4723
Mailing Address - Fax:
Practice Address - Street 1:1608 PARADISE LAKE DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5719
Practice Address - Country:US
Practice Address - Phone:860-997-4723
Practice Address - Fax:860-997-4723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1449103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty