25D1105421 CLIA NUMBER - GULF COAST PSYCHOTHERAPY

Laboratory Demographics

CLIA Number: 25D1105421

Facility Name: GULF COAST PSYCHOTHERAPY

Facility Address:
12231A ASHLEY DRIVE
GULFPORT, MS
ZIP 39503
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Facility Phone Number: 228 832-2400

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1417147398

Taxonomy: 101YM0800X - Counselor

CLIA Record

Field Name	Field Value
CLIA Number	25D1105421
LAB Type	Practitioner Other
Facility Name	GULF COAST PSYCHOTHERAPY
Street	12231A ASHLEY DRIVE
City	GULFPORT
State	MS
ZIP	39503
Phone	228 832-2400
CertificateType	4
CertificateEffectiveDate	9/23/2023
CertificateExpirationDate	9/22/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024