Healthcare Provider Details

I. General information

NPI: 1972788669
Provider Name (Legal Business Name): HARBORSIDE PSYCHIATRIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2008
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W. MCKENZIE STREET SUITE #117
PUNTA GORDA FL
33950
US

IV. Provider business mailing address

150 W. MCKENZIE STREET SUITE #117
PUNTA GORDA FL
33950-5500
US

V. Phone/Fax

Practice location:
  • Phone: 941-205-3333
  • Fax: 941-205-3334
Mailing address:
  • Phone: 941-205-3333
  • Fax: 941-205-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW7783
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberL07000124924
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME86547
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberL07000124924
License Number StateFL

VIII. Authorized Official

Name: MS. JOAN E. FLYNN
Title or Position: PARTNER
Credential: LCSW
Phone: 941-205-3333