Basic Information
| Provider Information | |||||||||
| NPI: | 1508864521 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYCARE BEHAVIORAL HEALTH INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HARBOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 DREW ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337593012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272819065 | ||||||||
| FaxNumber: | 8136352613 | ||||||||
| Practice Location | |||||||||
| Address1: | 7809 MASSACHUSETTS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346533028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278414200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | GORKEN | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7272819390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 283Q00000X | N | Hospitals | Psychiatric Hospital | 3336I0012X | PH13085 | FL | N | Suppliers | Pharmacy | Institutional Pharmacy | 2084B0040X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Behavioral Neurology & Neuropsychiatry |
ID Information
| ID | Type | State | Issuer | Description | 060297313 | 05 | FL | MEDICAID | 060297309 | 05 | FL | MEDICAID |