Provider Demographics
NPI:1679082978
Name:COASTAL MENTAL HEALTH & WELLNESS, LLC
Entity type:Organization
Organization Name:COASTAL MENTAL HEALTH & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBR
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFALCO CHARLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-928-9774
Mailing Address - Street 1:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34274-0728
Mailing Address - Country:US
Mailing Address - Phone:941-423-2728
Mailing Address - Fax:
Practice Address - Street 1:11705 EVENING WALK DRIVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34211
Practice Address - Country:US
Practice Address - Phone:941-928-9774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-29
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty