Provider Demographics
NPI:1962994525
Name:SEACOAST BEHAVIOR, LLC
Entity type:Organization
Organization Name:SEACOAST BEHAVIOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-836-0829
Mailing Address - Street 1:536 SHOREBIRD WAY
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:536 SHOREBIRD WAY
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932
Practice Address - Country:US
Practice Address - Phone:757-404-8176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-17-26403103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty