Provider Demographics
NPI:1700985462
Name:GULF COAST TREATMENT CENTER
Entity Type:Organization
Organization Name:GULF COAST TREATMENT CENTER
Other - Org Name:GULF COAST YOUTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KAPLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-863-4160
Mailing Address - Street 1:1015 MAR WALT DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547
Mailing Address - Country:US
Mailing Address - Phone:850-863-4160
Mailing Address - Fax:850-863-8576
Practice Address - Street 1:1015 MAR WALT DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-863-4160
Practice Address - Fax:850-863-8576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4454283Q00000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
104032Medicare ID - Type Unspecified