MEDICARE: COASTAL AUTISM THERAPY CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1447488945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL AUTISM THERAPY CENTER, INC.

Provider Business Mailing Address
First Line	:	110 PIPEMAKERS CIR STE 116
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-4168
Country	:	US
Telephone Number	:	912-507-1553
Fax Number	:	888-413-4567

Provider Business Practice Location Address
First Line	:	110 PIPEMAKERS CIR STE 116
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-4168
Country	:	US
Telephone Number	:	912-330-7171
Fax Number	:	888-413-4567

Authorized Official
Title or Position	:	CEO
Name	:	CRYSTAL FORD
Credential	:	APRN-BC, BCBA, LBA
Telephone Number	:	912-507-1553

Provider Enumeration Date	:	06/23/2009
Last Update Date	:	05/11/2026

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