Healthcare Provider Details

I. General information

NPI: 1891243440
Provider Name (Legal Business Name): BAY CENTRE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 ISABELLA INGRAM DR
PENSACOLA FL
32504-5032
US

IV. Provider business mailing address

4590 ISABELLA INGRAM DR
PENSACOLA FL
32504-5032
US

V. Phone/Fax

Practice location:
  • Phone: 850-619-5631
  • Fax: 850-308-7977
Mailing address:
  • Phone: 850-619-5631
  • Fax: 850-308-7977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH1271
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS185
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA79472
License Number StateFL

VIII. Authorized Official

Name: WANDA H TAYLOR
Title or Position: CEO
Credential: MCC
Phone: 850-619-5631