Provider Demographics
NPI:1194028555
Name:GULF COAST NEUROPSYCHOLOGY, LLC
Entity Type:Organization
Organization Name:GULF COAST NEUROPSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:WEITZEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:228-385-7733
Mailing Address - Street 1:45 HARDY COURT CTR
Mailing Address - Street 2:#113
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-2501
Mailing Address - Country:US
Mailing Address - Phone:228-385-7733
Mailing Address - Fax:228-539-1464
Practice Address - Street 1:16195C LANDON RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4121
Practice Address - Country:US
Practice Address - Phone:228-385-7733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS45-725103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty