MEDICARE: COASTAL MENTAL HEALTH SERVICE PROVIDERS

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	:	1831320985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL MENTAL HEALTH SERVICE PROVIDERS

Provider Business Mailing Address
First Line	:	104 WINNER AVE
Second Line	:	SUITE 1
City	:	CAROLINA BEACH
State	:	NC
Zip	:	28428-4801
Country	:	US
Telephone Number	:	910-707-0516
Fax Number	:	910-707-0516

Provider Business Practice Location Address
First Line	:	104 WINNER AVE
Second Line	:	SUITE 1
City	:	CAROLINA BEACH
State	:	NC
Zip	:	28428-4801
Country	:	US
Telephone Number	:	910-707-0516
Fax Number	:	910-707-0516

Authorized Official
Title or Position	:	ASSOCIATE EXECUTIVE DIRECTOR
Name	:	MRS. DIANE LYNN DOUGAN
Credential	:
Telephone Number	:	910-707-0516

Provider Enumeration Date	:	08/06/2009
Last Update Date	:	11/19/2009

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