Provider Demographics
NPI:1104044619
Name:EDDIE TESSNEAR
Entity Type:Organization
Organization Name:EDDIE TESSNEAR
Other - Org Name:COASTAL PSYCHOLOGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:TESSNEAR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:252-291-1100
Mailing Address - Street 1:2403 WOOTEN BLVD SW
Mailing Address - Street 2:SUITE E
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4463
Mailing Address - Country:US
Mailing Address - Phone:252-291-1100
Mailing Address - Fax:
Practice Address - Street 1:2403 WOOTEN BLVD SW
Practice Address - Street 2:SUITE E
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4463
Practice Address - Country:US
Practice Address - Phone:252-291-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-22
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1506103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0267LOtherBLUE CROSS BLUE SHIELD NC
NC6005109Medicaid
NC2813332Medicare ID - Type Unspecified