Healthcare Provider Details

I. General information

NPI: 1730953308
Provider Name (Legal Business Name): BAYSIDE BREAKTHROUGH PSYCHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 MANGROVE MANOR DR
APOLLO BEACH FL
33572-3552
US

IV. Provider business mailing address

152 MANGROVE MANOR DR
APOLLO BEACH FL
33572-3552
US

V. Phone/Fax

Practice location:
  • Phone: 727-496-8480
  • Fax:
Mailing address:
  • Phone: 727-496-8480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLE BIONDOLETTI
Title or Position: OWNER
Credential: PSYD
Phone: 305-393-2574