Provider Demographics
NPI:1790277689
Name:COASTAL THERAPY ASSOCIATES LLC
Entity Type:Organization
Organization Name:COASTAL THERAPY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:LAND
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:850-209-5935
Mailing Address - Street 1:3050 W HIGHWAY 98 UNIT B7
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-4718
Mailing Address - Country:US
Mailing Address - Phone:850-209-5935
Mailing Address - Fax:
Practice Address - Street 1:3050 W HIGHWAY 98 UNIT B7
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-4718
Practice Address - Country:US
Practice Address - Phone:850-209-5935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2801262363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty