Basic Information
| Provider Information | |||||||||
| NPI: | 1336654243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAYNARD | ||||||||
| FirstName: | JOHANNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MPH, CAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9662 PINE LAKE TRL | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337084521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133472237 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7207 N NEBRASKA AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336044916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132361182 | ||||||||
| FaxNumber: | 8132367551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2017 | ||||||||
| LastUpdateDate: | 12/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 2542 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | NONE | 01 | NONE | OTHER |