Provider Demographics
NPI:1588161384
Name:COASTAL PSYCHOLOGICAL SERVICES, INC.
Entity type:Organization
Organization Name:COASTAL PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LEATH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:949-385-2775
Mailing Address - Street 1:1400 QUAIL ST STE 136
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2788
Mailing Address - Country:US
Mailing Address - Phone:949-385-2775
Mailing Address - Fax:949-336-3763
Practice Address - Street 1:1400 QUAIL ST STE 136
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2788
Practice Address - Country:US
Practice Address - Phone:949-385-2775
Practice Address - Fax:949-336-3763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26109103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty