Provider Demographics
NPI:1891981866
Name:COASTAL COUNSELING ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:COASTAL COUNSELING ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-350-0004
Mailing Address - Street 1:115 HINTON AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-4785
Mailing Address - Country:US
Mailing Address - Phone:910-350-0004
Mailing Address - Fax:910-350-1206
Practice Address - Street 1:115 HINTON AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4785
Practice Address - Country:US
Practice Address - Phone:910-350-0004
Practice Address - Fax:910-350-1206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1680103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000486Medicaid
NC6000486Medicaid