Provider Demographics
NPI:1205609807
Name:COASTAL TRANQUILITY BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:COASTAL TRANQUILITY BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BAINUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-417-0654
Mailing Address - Street 1:110 COLISEUM XING # 5353
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5971
Mailing Address - Country:US
Mailing Address - Phone:757-752-8682
Mailing Address - Fax:757-432-3269
Practice Address - Street 1:925 OLD HOMESTEAD LN
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4013
Practice Address - Country:US
Practice Address - Phone:757-752-8682
Practice Address - Fax:757-432-3269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-06
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty