Provider Demographics
NPI:1154594950
Name:COASTAL MENTAL HEALTH CENTER INC
Entity type:Organization
Organization Name:COASTAL MENTAL HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SCALETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-614-4124
Mailing Address - Street 1:665 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4004
Mailing Address - Country:US
Mailing Address - Phone:407-712-4332
Mailing Address - Fax:888-217-4124
Practice Address - Street 1:101 BELLAGIO CIR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-5000
Practice Address - Country:US
Practice Address - Phone:800-614-4124
Practice Address - Fax:888-217-4124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-12
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000959600Medicaid