Provider Demographics
NPI:1699702654
Name:COASTAL PSYCHIATRY, LLC
Entity type:Organization
Organization Name:COASTAL PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:H
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-532-8549
Mailing Address - Street 1:1030 JENKINS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5704
Mailing Address - Country:US
Mailing Address - Phone:843-852-0083
Mailing Address - Fax:843-852-0087
Practice Address - Street 1:1030 JENKINS RD
Practice Address - Street 2:SUITE A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5704
Practice Address - Country:US
Practice Address - Phone:843-852-0083
Practice Address - Fax:843-852-0087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3354Medicaid
SCGP3354Medicaid