Provider Demographics
NPI:1427850940
Name:COASTAL CLARITY COLLECTIVE LLC
Entity type:Organization
Organization Name:COASTAL CLARITY COLLECTIVE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:228-206-5116
Mailing Address - Street 1:101 EDMUND DR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8837 LORRAINE RD UNIT A-1
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-5079
Practice Address - Country:US
Practice Address - Phone:228-206-5116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-25
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty