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General NPI Number Information
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NPI Number | 1588161384
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Entity Type | Organization
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Legal Business Name | COASTAL PSYCHOLOGICAL SERVICES, INC.
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Dates
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Enumeration Date | 04/09/2018
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Last Update Date | 05/31/2024
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Provider Practice Location Address
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Address Line | 1400 QUAIL ST STE 136
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City | NEWPORT BEACH
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State | CA
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Zip | 92660-2788
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Country | US
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Telephone | 949-385-2775
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Fax | 949-336-3763
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Provider Business Mailing Address
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Address Line | 1400 QUAIL ST STE 136
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City | NEWPORT BEACH
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State | CA
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Zip | 92660-2788
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Country | US
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Telephone | 949-385-2775
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Fax | 949-336-3763
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JENNIFER LEATH
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Credential | PSYD
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Telephone | 949-385-2775
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY26109
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License Number State | CA
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