Provider Demographics
NPI:1710517412
Name:GULF COAST THERAPY CENTER
Entity Type:Organization
Organization Name:GULF COAST THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:MACEDONIO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:646-239-8210
Mailing Address - Street 1:807 N WACO AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3971
Mailing Address - Country:US
Mailing Address - Phone:941-500-9796
Mailing Address - Fax:316-721-8139
Practice Address - Street 1:2520 TAMIAMI TRL N STE 18
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:FL
Practice Address - Zip Code:34275-3434
Practice Address - Country:US
Practice Address - Phone:941-500-9796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty