Provider Demographics
NPI:1659011237
Name:COASTAL CENTER FOR CONNECTION
Entity type:Organization
Organization Name:COASTAL CENTER FOR CONNECTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:760-421-8455
Mailing Address - Street 1:9518 3RD BAY ST UNIT 120
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-1013
Mailing Address - Country:US
Mailing Address - Phone:760-421-8455
Mailing Address - Fax:
Practice Address - Street 1:317 OFFICE SQUARE LN STE B101
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3652
Practice Address - Country:US
Practice Address - Phone:757-403-4953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)