Healthcare Provider Details

I. General information

NPI: 1255146569
Provider Name (Legal Business Name): PRESTIGE ADDICTION TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 W 23RD ST STE C
PANAMA CITY FL
32405-4541
US

IV. Provider business mailing address

2117 CAROLINE ST
MANDEVILLE LA
70448-3707
US

V. Phone/Fax

Practice location:
  • Phone: 850-640-1554
  • Fax:
Mailing address:
  • Phone: 985-377-8909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN NORRIS
Title or Position: OWNER
Credential:
Phone: 985-377-8909