Healthcare Provider Details

I. General information

NPI: 1790275956
Provider Name (Legal Business Name): GULF COAST WELLNESS CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2318 PASS RD STE 7C
BILOXI MS
39531
US

IV. Provider business mailing address

2318 PASS RD STE 7C
BILOXI MS
39531-4044
US

V. Phone/Fax

Practice location:
  • Phone: 228-388-6282
  • Fax: 228-388-7150
Mailing address:
  • Phone: 228-388-6282
  • Fax: 228-388-7150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0233
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number16798
License Number StateMS

VIII. Authorized Official

Name: DR. MINNIE O'BANNER
Title or Position: LICENSED MARRIAGE FAMILY THERAPTIST
Credential: DD, MSSW, LMFT
Phone: 228-388-6282