Provider Demographics
NPI:1225560410
Name:GULF COAST PLAY THERAPY CLINIC, LLC
Entity Type:Organization
Organization Name:GULF COAST PLAY THERAPY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:INFANTA
Authorized Official - Middle Name:CHANTEL
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:EDS, LPC, NCC, RPT
Authorized Official - Phone:228-697-7280
Mailing Address - Street 1:370 COURTHOUSE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-1889
Mailing Address - Country:US
Mailing Address - Phone:228-224-2258
Mailing Address - Fax:228-896-1155
Practice Address - Street 1:370 COURTHOUSE RD STE 102
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1889
Practice Address - Country:US
Practice Address - Phone:228-224-2258
Practice Address - Fax:228-896-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2104251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1427580612Medicaid
MS1225560410Medicaid