Basic Information
| Provider Information | |||||||||
| NPI: | 1972800555 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHSIDE BEHAVIORAL HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHSIDE BEHAVIORAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 02/17/2011 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | MORROW | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8139778700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
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 | FL | Y | Hospitals | Psychiatric Hospital |
No ID Information.