=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184053688
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLD COAST YOUTH SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2013
-----------------------------------------------------
Last Update Date | 11/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3230 E. IMPERIAL HWY STE. 315
-----------------------------------------------------
City | BREA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-524-3799
-----------------------------------------------------
Fax | 714-528-3416
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2067
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-524-3799
-----------------------------------------------------
Fax | 714-528-3416
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C.O.O.
-----------------------------------------------------
Name | MARDI HARVEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-524-3799
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------