Provider Demographics
NPI:1891303244
Name:SHORELINE CENTER FOR EXCEPTIONAL STUDENTS, LLC
Entity Type:Organization
Organization Name:SHORELINE CENTER FOR EXCEPTIONAL STUDENTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CUMBIE
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:850-227-5759
Mailing Address - Street 1:528 CECIL G COSTIN SR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-1754
Mailing Address - Country:US
Mailing Address - Phone:850-227-5759
Mailing Address - Fax:
Practice Address - Street 1:528 CECIL G COSTIN SR BLVD STE A
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1754
Practice Address - Country:US
Practice Address - Phone:850-227-1163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty