Provider Demographics
NPI:1770856635
Name:COACHING 4 KIDS, LLC
Entity Type:Organization
Organization Name:COACHING 4 KIDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:727-341-1000
Mailing Address - Street 1:6739 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-1307
Mailing Address - Country:US
Mailing Address - Phone:727-341-1000
Mailing Address - Fax:727-341-1000
Practice Address - Street 1:6737 1ST AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1307
Practice Address - Country:US
Practice Address - Phone:727-341-1000
Practice Address - Fax:727-341-1000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW6791302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization