Healthcare Provider Details

I. General information

NPI: 1922562628
Provider Name (Legal Business Name): BLUEWATER BEHAVIORAL HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2019
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 E HIGHWAY 20 STE 208
NICEVILLE FL
32578-9735
US

IV. Provider business mailing address

4400 E HIGHWAY 20 STE 208
NICEVILLE FL
32578-9735
US

V. Phone/Fax

Practice location:
  • Phone: 575-520-1230
  • Fax: 773-492-8765
Mailing address:
  • Phone: 850-797-2598
  • Fax: 773-492-8765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LEIGH GAYLE POWERS
Title or Position: OWNER/PROVIDER
Credential: DNP, APRN, PMHNP-BC
Phone: 850-797-2598