Provider Demographics
NPI:1447684097
Name:COASTAL WELLNESS, LLC
Entity type:Organization
Organization Name:COASTAL WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HISAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-889-5475
Mailing Address - Street 1:9929 SPID DR STE 113
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-5164
Mailing Address - Country:US
Mailing Address - Phone:432-889-5475
Mailing Address - Fax:
Practice Address - Street 1:9929 SPID DR STE 113
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78418-5164
Practice Address - Country:US
Practice Address - Phone:432-889-5475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX801800621101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty