Healthcare Provider Details

I. General information

NPI: 1912670647
Provider Name (Legal Business Name): PBH PROFESSIONAL GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W GRANADA BLVD STE 1A
ORMOND BEACH FL
32174-8157
US

IV. Provider business mailing address

103 POWELL CT STE 100
BRENTWOOD TN
37027-5050
US

V. Phone/Fax

Practice location:
  • Phone: 386-506-8110
  • Fax: 386-463-2170
Mailing address:
  • Phone: 615-308-7871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: FLORA SADRI-AZARBAYEJANI
Title or Position: PRESIDENT AND SECRETARY
Credential: D.O.
Phone: 413-522-9246