Provider Demographics
NPI:1780869297
Name:COASTAL SUPPORT SPECIALISTS, INC.
Entity type:Organization
Organization Name:COASTAL SUPPORT SPECIALISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CAMILLUS
Authorized Official - Middle Name:(CASE) P
Authorized Official - Last Name:VAN DER KUIJL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-233-1374
Mailing Address - Street 1:2460 DELANEY AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6062
Mailing Address - Country:US
Mailing Address - Phone:910-792-6130
Mailing Address - Fax:910-792-6132
Practice Address - Street 1:2460 DELANEY AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6062
Practice Address - Country:US
Practice Address - Phone:910-792-6130
Practice Address - Fax:910-792-6132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008286Medicaid
NC8702029Medicaid