Healthcare Provider Details

I. General information

NPI: 1033778659
Provider Name (Legal Business Name): EMERALD COAST BEHAVIOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 05/19/2022
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5747 E BAY BLVD
GULF BREEZE FL
32563-9665
US

IV. Provider business mailing address

5747 E BAY BLVD
GULF BREEZE FL
32563-9665
US

V. Phone/Fax

Practice location:
  • Phone: 850-307-8811
  • Fax:
Mailing address:
  • Phone: 850-307-8811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: CANDICE LEE WOLFF
Title or Position: OWNER
Credential:
Phone: 850-307-8811