Healthcare Provider Details

I. General information

NPI: 1750644811
Provider Name (Legal Business Name): NORTHSIDE BEHAVIORAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12512 BRUCE B DOWNS BLVD
TAMPA FL
33612-9209
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 813-977-8700
  • Fax: 813-971-2029
Mailing address:
  • Phone: 727-315-6974
  • Fax: 813-635-2613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: LYNDA GORKEN
Title or Position: VICE PRESIDENT
Credential:
Phone: 727-281-9202