Provider Demographics
NPI:1932408143
Name:COASTAL BEHAVIOR ANALYSIS, LLC
Entity Type:Organization
Organization Name:COASTAL BEHAVIOR ANALYSIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PIERCE
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:BCBA
Authorized Official - Phone:772-713-0108
Mailing Address - Street 1:1515 INDIAN RIVER BLVD
Mailing Address - Street 2:SUITE A210
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-5639
Mailing Address - Country:US
Mailing Address - Phone:774-774-8224
Mailing Address - Fax:772-774-8275
Practice Address - Street 1:1515 INDIAN RIVER BLVD
Practice Address - Street 2:SUITE A210
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5639
Practice Address - Country:US
Practice Address - Phone:774-774-8224
Practice Address - Fax:772-774-8275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1042028103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003810000Medicaid