MEDICARE: COASTAL BEHAVIORAL SERVICES, 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	:	1598345514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL BEHAVIORAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	10135 MONTAGUE ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-1857
Country	:	US
Telephone Number	:	813-401-2539
Fax Number	:

Provider Business Practice Location Address
First Line	:	10135 MONTAGUE ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-1857
Country	:	US
Telephone Number	:	813-401-2539
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CRYSTAL LAGOR
Credential	:	BCBA
Telephone Number	:	813-401-2539

Provider Enumeration Date	:	04/13/2021
Last Update Date	:	04/16/2021

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