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General NPI Number Information
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NPI Number | 1730676057
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Entity Type | Organization
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Legal Business Name | COASTAL COUNSELING PCB, LLC
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Dates
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Enumeration Date | 04/23/2018
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Last Update Date | 04/23/2018
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Provider Practice Location Address
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Address Line | 400 THOMAS DR. 7108
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City | PANAMA CITY BEACH
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State | FL
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Zip | 32408
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Country | US
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Telephone | 850-733-7720
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Fax |
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Provider Business Mailing Address
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Address Line | 2522 PELICAN BAY DR
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City | PANAMA CITY BEACH
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State | FL
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Zip | 32408-7046
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Country | US
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Telephone | 850-733-7720
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Fax |
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Authorized Official
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Title or Position | MANAGER/COUNSELOR
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Name | DR. TREGON FITCH
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Credential | LMHC
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Telephone | 850-733-7720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 11097
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License Number State | FL
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