Healthcare Provider Details

I. General information

NPI: 1396472411
Provider Name (Legal Business Name): GULF COAST NEUROPSYCHOLOGY AND NEURO-REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1746 PASS RD
BILOXI MS
39531-3330
US

IV. Provider business mailing address

1746 PASS RD
BILOXI MS
39531-3330
US

V. Phone/Fax

Practice location:
  • Phone: 228-465-2524
  • Fax: 228-248-0020
Mailing address:
  • Phone: 228-465-2524
  • Fax: 228-248-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: RACHA FARES
Title or Position: CLINICAL NEUROPSYCHOLOGIST
Credential: PSYD
Phone: 228-465-2524