Provider Demographics
NPI:1336318542
Name:COASTAL COUNSELING CENTER, INC.
Entity Type:Organization
Organization Name:COASTAL COUNSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:912-729-1120
Mailing Address - Street 1:104 LAKESHORE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3803
Mailing Address - Country:US
Mailing Address - Phone:912-729-1120
Mailing Address - Fax:912-729-1150
Practice Address - Street 1:104 LAKESHORE DR
Practice Address - Street 2:SUITE D
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3803
Practice Address - Country:US
Practice Address - Phone:912-729-1120
Practice Address - Fax:912-729-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health