Provider Demographics
NPI:1790275956
Name:GULF COAST WELLNESS CENTER INC
Entity Type:Organization
Organization Name:GULF COAST WELLNESS CENTER INC
Other - Org Name:GULF COAST WELLNESS CENTER INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED MARRIAGE FAMILY THERAPTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MINNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DD, MSSW, LMFT
Authorized Official - Phone:228-388-6282
Mailing Address - Street 1:2318 PASS RD STE 7C
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4044
Mailing Address - Country:US
Mailing Address - Phone:228-388-6282
Mailing Address - Fax:228-388-7150
Practice Address - Street 1:2318 PASS RD STE 7C
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531
Practice Address - Country:US
Practice Address - Phone:228-388-6282
Practice Address - Fax:228-388-7150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-14
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST0233106H00000X
MS16798208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty