Healthcare Provider Details

I. General information

NPI: 1588107759
Provider Name (Legal Business Name): COASTAL MEDICAL AND PSYCHIATRIC SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2016
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 DILIGENCE DR STE 206
NEWPORT NEWS VA
23606-4272
US

IV. Provider business mailing address

825 DILIGENCE DR STE 206
NEWPORT NEWS VA
23606-4272
US

V. Phone/Fax

Practice location:
  • Phone: 757-310-6900
  • Fax: 757-240-5936
Mailing address:
  • Phone: 757-310-6900
  • Fax: 757-240-5936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number0024174260
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number0024174260
License Number StateVA

VIII. Authorized Official

Name: JESSICA ADAMS
Title or Position: CEO
Credential: N.P.
Phone: 757-310-6900