MEDICARE: COASTAL NEUROPSYCHOLOGY, 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	103TB0200X	Cognitive & Behavioral Psychologist	PY8604	FL
2	103TC0700X	Clinical Psychologist	PY8604	FL
3	103TC1900X	Counseling Psychologist	PY8604	FL
4	103TE1100X	Exercise & Sports Psychologist	PY8604	FL
5	103TF0000X	Family Psychologist	PY8604	FL
6	103TM1800X	Intellectual & Developmental Disabilities Psychologist	PY8604	FL
7	103TS0200X	School Psychologist	PY8604	FL
8	103G00000X	Clinical Neuropsychologist

General Provider Information

NPI Number	:	1871956805
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL NEUROPSYCHOLOGY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 8
Second Line	:
City	:	TERRA CEIA
State	:	FL
Zip	:	34250-0008
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 GULF TO BAY BLVD STE 300
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33759-4304
Country	:	US
Telephone Number	:	800-687-1938
Fax Number	:	727-495-7233

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STEFANIE COPPES
Credential	:	PH.D.
Telephone Number	:	800-687-1938

Provider Enumeration Date	:	03/29/2016
Last Update Date	:	07/05/2022

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