Basic Information
| Provider Information | |||||||||
| NPI: | 1912912874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEABREEZE BEHAVIORAL MEDICINE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 495755 | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339495755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417669555 | ||||||||
| FaxNumber: | 9417661511 | ||||||||
| Practice Location | |||||||||
| Address1: | 923 DEL PRADO BLVD S | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339903652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392428773 | ||||||||
| FaxNumber: | 2392428775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 07/25/2007 | ||||||||
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| AuthorizedOfficialLastName: | ARIAS | ||||||||
| AuthorizedOfficialFirstName: | BERNARDO | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9417669555 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 38239A | 01 | FL | FLORIDA BC & BS | OTHER |