Provider Demographics
NPI:1972039584
Name:GULF COAST NEUROPSYCHOLOGY, LLC
Entity Type:Organization
Organization Name:GULF COAST NEUROPSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:KELLEY
Authorized Official - Last Name:O'NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:941-993-3074
Mailing Address - Street 1:2650 BAHIA VISTA ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2635
Mailing Address - Country:US
Mailing Address - Phone:941-993-3074
Mailing Address - Fax:941-722-3039
Practice Address - Street 1:2650 BAHIA VISTA ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2635
Practice Address - Country:US
Practice Address - Phone:941-993-3074
Practice Address - Fax:941-722-3039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7351103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU8900XMedicare UPIN