Provider Demographics
NPI:1730676057
Name:COASTAL COUNSELING PCB, LLC
Entity Type:Organization
Organization Name:COASTAL COUNSELING PCB, LLC
Other - Org Name:COASTAL COUNSELING PCB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TREGON
Authorized Official - Middle Name:
Authorized Official - Last Name:FITCH
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:850-733-7720
Mailing Address - Street 1:2522 PELICAN BAY DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32408-7046
Mailing Address - Country:US
Mailing Address - Phone:850-733-7720
Mailing Address - Fax:
Practice Address - Street 1:400 THOMAS DR.
Practice Address - Street 2:7108
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32408
Practice Address - Country:US
Practice Address - Phone:850-733-7720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11097261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)