Healthcare Provider Details

I. General information

NPI: 1750828364
Provider Name (Legal Business Name): COASTAL PLAY 2 GROW THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2017
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2387 LANTERN ST
CHARLESTON SC
29414-4850
US

IV. Provider business mailing address

2387 LANTERN ST
CHARLESTON SC
29414-4850
US

V. Phone/Fax

Practice location:
  • Phone: 317-750-9879
  • Fax: 888-965-4405
Mailing address:
  • Phone:
  • Fax: 888-965-4405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: COURTNEY JARRARD
Title or Position: BILLER
Credential:
Phone: 843-568-4786