Healthcare Provider Details

I. General information

NPI: 1043996986
Provider Name (Legal Business Name): COASTLINE NEUROPSYCHIATRIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 S PALAFOX ST SUITE 300-L
PENSACOLA FL
32502
US

IV. Provider business mailing address

304 W GADSDEN ST
PENSACOLA FL
32501
US

V. Phone/Fax

Practice location:
  • Phone: 850-341-4896
  • Fax: 850-433-1996
Mailing address:
  • Phone: 850-341-4896
  • Fax: 850-433-1996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN NEIL GROOM
Title or Position: OWNER
Credential: PH.D.
Phone: 850-341-4896