Provider Demographics
NPI:1851800726
Name:COASTAL ABA, LLC
Entity Type:Organization
Organization Name:COASTAL ABA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:ALTMAN
Authorized Official - Last Name:BRUM
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:727-888-3296
Mailing Address - Street 1:3135 1ST AVE N, PO BOX 12844
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33730
Mailing Address - Country:US
Mailing Address - Phone:727-999-0583
Mailing Address - Fax:855-306-2505
Practice Address - Street 1:6001 41ST AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-5221
Practice Address - Country:US
Practice Address - Phone:727-656-6045
Practice Address - Fax:727-656-6045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-23
Last Update Date:2017-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1073972451Medicaid
FL1700266871Medicaid