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General NPI Number Information
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NPI Number | 1225560410
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Entity Type | Organization
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Legal Business Name | GULF COAST PLAY THERAPY CLINIC, LLC
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Dates
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Enumeration Date | 03/28/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 370 COURTHOUSE RD STE 102
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City | GULFPORT
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State | MS
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Zip | 39507-1889
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Country | US
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Telephone | 228-224-2258
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Fax | 228-896-1155
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Provider Business Mailing Address
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Address Line | 370 COURTHOUSE RD STE 102
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City | GULFPORT
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State | MS
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Zip | 39507-1889
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Country | US
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Telephone | 228-224-2258
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Fax | 228-896-1155
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Authorized Official
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Title or Position | OWNER
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Name | INFANTA CHANTEL WHITE
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Credential | ED.S., LPC, NCC, RPT
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Telephone | 228-697-7280
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 2104
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License Number State | MS
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