Provider Demographics
NPI:1629346606
Name:GULF COAST PSYCHOLOGY PLLC
Entity Type:Organization
Organization Name:GULF COAST PSYCHOLOGY PLLC
Other - Org Name:MARY ANN GANSLE SOLE MBR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GANSLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:361-445-4080
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-0002
Mailing Address - Country:US
Mailing Address - Phone:361-445-4080
Mailing Address - Fax:888-413-3010
Practice Address - Street 1:1700 WILDCAT DR STE D
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-2817
Practice Address - Country:US
Practice Address - Phone:361-445-4080
Practice Address - Fax:888-413-3010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35139103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty