Healthcare Provider Details

I. General information

NPI: 1780869297
Provider Name (Legal Business Name): COASTAL SUPPORT SPECIALISTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 DELANEY AVE
WILMINGTON NC
28403-6062
US

IV. Provider business mailing address

2460 DELANEY AVE
WILMINGTON NC
28403-6062
US

V. Phone/Fax

Practice location:
  • Phone: 910-792-6130
  • Fax: 910-792-6132
Mailing address:
  • Phone: 910-792-6130
  • Fax: 910-792-6132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. CAMILLUS (CASE) P. VAN DER KUIJL
Title or Position: FINANCIAL OFFICER
Credential:
Phone: 910-233-1374