Healthcare Provider Details

I. General information

NPI: 1447569264
Provider Name (Legal Business Name): GULF COAST REHABILITATION SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 HENDERSON BLVD SUITE 405
TAMPA FL
33629-5037
US

IV. Provider business mailing address

PO BOX 13798
TAMPA FL
33681-3798
US

V. Phone/Fax

Practice location:
  • Phone: 877-957-3422
  • Fax: 877-957-3422
Mailing address:
  • Phone: 877-957-3422
  • Fax: 877-957-3422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberSW7468
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberSW7468
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW7468
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMH11189
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5525
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH11189
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberMH11189
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberSW7468
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW7468
License Number StateFL
# 10
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5552
License Number StateFL
# 11
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH11189
License Number StateFL

VIII. Authorized Official

Name: DR. JOSHUA ELLIOTT SHANNON
Title or Position: CEO
Credential: SAP,CAP,CEAP,LMHC
Phone: 877-957-3422