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General NPI Number Information
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NPI Number | 1942648043
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Entity Type | Organization
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Legal Business Name | COASTAL SERENITY PSYCHIATRY PLLC
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Dates
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Enumeration Date | 06/11/2013
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Last Update Date | 08/29/2016
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Provider Practice Location Address
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Address Line | 824 GUM BRANCH RD SUITE Q
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City | JACKSONVILLE
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State | NC
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Zip | 28540-6272
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Country | US
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Telephone | 814-602-9096
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Fax | 910-346-1054
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Provider Business Mailing Address
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Address Line | 201 CANAAN CT
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City | JACKSONVILLE
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State | NC
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Zip | 28546-5280
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Country | US
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Telephone | 814-602-9096
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Fax | 910-346-1054
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARIE ANN SPRAGUE
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Credential | D.O.
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Telephone | 814-602-9096
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 2010-00175
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License Number State | NC
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