Provider Demographics
NPI:1396472411
Name:GULF COAST NEUROPSYCHOLOGY AND NEURO-REHABILITATION
Entity type:Organization
Organization Name:GULF COAST NEUROPSYCHOLOGY AND NEURO-REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-465-2524
Mailing Address - Street 1:14612 PORTEAUX BAY DR
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-7327
Mailing Address - Country:US
Mailing Address - Phone:321-432-4722
Mailing Address - Fax:
Practice Address - Street 1:8837 LORRAINE RD STE B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-5081
Practice Address - Country:US
Practice Address - Phone:228-465-2524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty