MEDICARE: GULF COAST AUTISM CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013517143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GULF COAST AUTISM CLINIC, LLC

Provider Business Mailing Address
First Line	:	2404 RUTH HENTZ AVE BLDG B
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2258
Country	:	US
Telephone Number	:	850-628-7572
Fax Number	:

Provider Business Practice Location Address
First Line	:	2404 RUTH HENTZ AVE BLDG B
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2258
Country	:	US
Telephone Number	:	850-628-7572
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KURYN PATTERSON
Credential	:	BCBA
Telephone Number	:	850-628-7572

Provider Enumeration Date	:	10/28/2020
Last Update Date	:	10/28/2020

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