Provider Demographics
NPI:1245013648
Name:COASTAL THERAPY GROUP
Entity type:Organization
Organization Name:COASTAL THERAPY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHISEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:908-295-4855
Mailing Address - Street 1:25 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-1935
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:167 BLUFFTON RD STE I
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-6250
Practice Address - Country:US
Practice Address - Phone:908-295-4855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty