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General NPI Number Information
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NPI Number | 1528353729
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Entity Type | Organization
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Legal Business Name | COASTAL NEUROTHERAPY, P.A.
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Dates
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Enumeration Date | 06/15/2011
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Last Update Date | 06/15/2011
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Provider Practice Location Address
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Address Line | 200 VALENCIA DR SUITE 109
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City | JACKSONVILLE
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State | NC
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Zip | 28546-6311
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Country | US
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Telephone | 910-353-1760
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Fax |
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Provider Business Mailing Address
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Address Line | 200 VALENCIA DR SUITE 109
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City | JACKSONVILLE
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State | NC
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Zip | 28546-6311
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DAVID HAGEDORN
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Credential | PH.D.
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Telephone | 910-353-1760
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 3745
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License Number State | NC
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