Basic Information
| Provider Information | |||||||||
| NPI: | 1669498002 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHSIDE BEHAVIORAL HEALTH CENTER, INC. | ||||||||
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| OtherOrganizationName: | NORTHSIDE MENTAL HEALTH CTR, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12512 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336129209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139778700 | ||||||||
| FaxNumber: | 8139712029 | ||||||||
| Practice Location | |||||||||
| Address1: | 12512 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139778700 | ||||||||
| FaxNumber: | 8139712029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | MORROW | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8139778700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | N | Hospitals | Psychiatric Hospital | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 251B00000X | N | Agencies | Case Management | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 060370801 | 05 | FL | MEDICAID | 060370800 | 05 | FL | MEDICAID |