Provider Demographics
NPI:1851631048
Name:SOUTH COASTAL COUNSELING INC
Entity Type:Organization
Organization Name:SOUTH COASTAL COUNSELING INC
Other - Org Name:SOUTH COASTAL COUNSELING INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JONIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:GUNN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:912-545-9893
Mailing Address - Street 1:116 WELSH PONY TRL NE
Mailing Address - Street 2:
Mailing Address - City:LUDOWICI
Mailing Address - State:GA
Mailing Address - Zip Code:31316-7839
Mailing Address - Country:US
Mailing Address - Phone:912-610-3200
Mailing Address - Fax:912-545-0041
Practice Address - Street 1:118 N MCDONALD STREET
Practice Address - Street 2:STE-C
Practice Address - City:LUDOWICI
Practice Address - State:GA
Practice Address - Zip Code:31316-7839
Practice Address - Country:US
Practice Address - Phone:912-545-9893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW004492251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2021806812Medicare PIN