Basic Information
| Provider Information | |||||||||
| NPI: | 1750644811 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHSIDE BEHAVIORAL HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | NORTHSIDE BEHAVIORAL HEALTH CENTER INC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 336129209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139778700 | ||||||||
| FaxNumber: | 8139712029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2012 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUST | ||||||||
| AuthorizedOfficialFirstName: | KRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8139778700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMHC | ||||||||
| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 060370801 | 05 | FL | MEDICAID |