Provider Demographics
NPI:1437322237
Name:COASTAL COUNSELING & COACHING, INC
Entity Type:Organization
Organization Name:COASTAL COUNSELING & COACHING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:NICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:949-222-6688
Mailing Address - Street 1:280 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7526
Mailing Address - Country:US
Mailing Address - Phone:949-222-6688
Mailing Address - Fax:949-716-7885
Practice Address - Street 1:280 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7526
Practice Address - Country:US
Practice Address - Phone:949-222-6688
Practice Address - Fax:949-716-7885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20446251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY20446AOtherMEDICARE - KFN
CA20446OtherPSYCHOLOGY LICENSE - KFN
CAC2942646OtherCA CORPORATION