Healthcare Provider Details

I. General information

NPI: 1609314293
Provider Name (Legal Business Name): COASTAL HAVEN COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 RONNIE CT STE 2
MYRTLE BEACH SC
29579-4192
US

IV. Provider business mailing address

220 RONNIE CT STE 2
MYRTLE BEACH SC
29579-4192
US

V. Phone/Fax

Practice location:
  • Phone: 843-945-0346
  • Fax: 843-432-3091
Mailing address:
  • Phone: 843-945-0346
  • Fax: 843-432-3091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6522
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SANDRA ELAINE QUAST
Title or Position: LPC
Credential:
Phone: 843-945-0346