Provider Demographics
NPI:1811729015
Name:COASTLINE MENTAL HEALTH LLC
Entity type:Organization
Organization Name:COASTLINE MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:PULLAM
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C, PMHNP-B
Authorized Official - Phone:850-368-4670
Mailing Address - Street 1:1723 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4600
Mailing Address - Country:US
Mailing Address - Phone:850-368-4670
Mailing Address - Fax:
Practice Address - Street 1:1723 PINE AVE
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-4600
Practice Address - Country:US
Practice Address - Phone:850-368-4670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty