Provider Demographics
NPI:1730494733
Name:COASTAL PEDIATRIC THERAPY SERVICES
Entity Type:Organization
Organization Name:COASTAL PEDIATRIC THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:252-422-5584
Mailing Address - Street 1:705 MANDOLIN LN
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28570-9366
Mailing Address - Country:US
Mailing Address - Phone:252-422-5584
Mailing Address - Fax:252-223-2756
Practice Address - Street 1:705 MANDOLIN LN
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:NC
Practice Address - Zip Code:28570-9366
Practice Address - Country:US
Practice Address - Phone:252-422-5584
Practice Address - Fax:252-223-2756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty