Provider Demographics
NPI:1407216906
Name:COASTLINE BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:COASTLINE BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIESING
Authorized Official - Suffix:
Authorized Official - Credentials:MHW CATC
Authorized Official - Phone:949-300-1657
Mailing Address - Street 1:2102 BUSINESS CENTER DR # 121
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-1001
Mailing Address - Country:US
Mailing Address - Phone:949-300-1657
Mailing Address - Fax:
Practice Address - Street 1:2102 BUSINESS CENTER DR # 121
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-1001
Practice Address - Country:US
Practice Address - Phone:949-300-1657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTLINE RECOVERY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300630AP101YA0400X, 101YM0800X, 103TA0400X, 103TP2701X, 1041C0700X
CA14445363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300630APOtherDEPARTMENT OF HEALTHCARE SERVICES