Provider Demographics
NPI:1447569264
Name:GULF COAST REHABILITATION SERVICES, INC.
Entity Type:Organization
Organization Name:GULF COAST REHABILITATION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:ELLIOTT
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:SAP,CAP,CEAP,LMHC
Authorized Official - Phone:877-957-3422
Mailing Address - Street 1:PO BOX 13798
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33681-3798
Mailing Address - Country:US
Mailing Address - Phone:877-957-3422
Mailing Address - Fax:877-957-3422
Practice Address - Street 1:3825 HENDERSON BLVD
Practice Address - Street 2:SUITE 405
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5037
Practice Address - Country:US
Practice Address - Phone:877-957-3422
Practice Address - Fax:877-957-3422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11189101Y00000X, 101YM0800X, 101YP2500X, 102L00000X
FL5525101YA0400X
FL5552101YA0400X
FLSW7468101YP2500X, 102L00000X, 103K00000X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty