Healthcare Provider Details

I. General information

NPI: 1417934175
Provider Name (Legal Business Name): GULF COAST MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BROAD AVE
GULFPORT MS
39501-3603
US

IV. Provider business mailing address

1600 BROAD AVE
GULFPORT MS
39501-3603
US

V. Phone/Fax

Practice location:
  • Phone: 228-863-1132
  • Fax: 228-865-1700
Mailing address:
  • Phone: 228-863-1132
  • Fax: 228-865-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberREG13-SO-01
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberR-13-1
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MARY E JONES
Title or Position: CFO
Credential: CPA
Phone: 228-863-1132