Basic Information
| Provider Information | |||||||||
| NPI: | 1750671095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSIDE MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12512 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336129209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139778700 | ||||||||
| FaxNumber: | 8139790503 | ||||||||
| Practice Location | |||||||||
| Address1: | 12512 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336129209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139778700 | ||||||||
| FaxNumber: | 8139790503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2011 | ||||||||
| LastUpdateDate: | 04/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | MARSHA | ||||||||
| AuthorizedOfficialMiddleName: | LEWIS | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8139778700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | L.C.S.W. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | FL | Y | Hospital Units | Psychiatric Unit |
No ID Information.