Healthcare Provider Details

I. General information

NPI: 1659672715
Provider Name (Legal Business Name): NORTHSIDE BEHAVIORAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2010
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12512 BRUCE B DOWNS BLVD
TAMPA FL
33612-9209
US

IV. Provider business mailing address

12512 BRUCE B DOWNS BLVD
TAMPA FL
33612-9209
US

V. Phone/Fax

Practice location:
  • Phone: 813-977-8700
  • Fax: 813-971-2029
Mailing address:
  • Phone: 813-977-8700
  • Fax: 813-971-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number8522
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA M HUST
Title or Position: DIRECTOR OF OPERATIONS
Credential: LMHC
Phone: 813-977-8700