Healthcare Provider Details

I. General information

NPI: 1588005698
Provider Name (Legal Business Name): COASTAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 CONNECTICUT AVE NW SUITE 100
WASHINGTON DC
20008-4530
US

IV. Provider business mailing address

3801 CONNECTICUT AVE NW SUITE 100
WASHINGTON DC
20008-4530
US

V. Phone/Fax

Practice location:
  • Phone: 202-525-1542
  • Fax:
Mailing address:
  • Phone: 202-525-1542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberSLP000685
License Number StateDC

VIII. Authorized Official

Name: QUIANA MITCHEM
Title or Position: DIRECTOR OF THERAPY
Credential:
Phone: 202-525-1542