Provider Demographics
NPI:1851359780
Name:BEACON BEHAVIORAL HEALTH GULF COAST INC
Entity Type:Organization
Organization Name:BEACON BEHAVIORAL HEALTH GULF COAST INC
Other - Org Name:SYNERGY BEHAVIORAL HEALTH GULF COAST INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:225-810-4040
Mailing Address - Street 1:9938 AIRLINE HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8100
Mailing Address - Country:US
Mailing Address - Phone:225-810-4040
Mailing Address - Fax:225-810-4050
Practice Address - Street 1:12450 SHORTCUT ROAD
Practice Address - Street 2:SUITE E
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532
Practice Address - Country:US
Practice Address - Phone:228-392-3240
Practice Address - Fax:228-392-4957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
254618Medicare ID - Type Unspecified