Healthcare Provider Details

I. General information

NPI: 1043145345
Provider Name (Legal Business Name): NEUROBALANCE PSYCHIATRY & BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4237 SALT SPRINGS LN
LAKELAND FL
33811-1893
US

IV. Provider business mailing address

4237 SALT SPRINGS LN
LAKELAND FL
33811-1893
US

V. Phone/Fax

Practice location:
  • Phone: 954-470-5460
  • Fax:
Mailing address:
  • Phone: 954-470-5460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SANTAY SHAW-RUSSELL
Title or Position: PRESIDENT
Credential: PMHNP-BC
Phone: 954-470-5460