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General NPI Number Information
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NPI Number | 1134775976
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Entity Type | Organization
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Legal Business Name | BAYSIDE RECOVERY AND WELLNESS CENTER LLC
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Dates
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Enumeration Date | 08/16/2019
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Last Update Date | 12/13/2021
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Provider Practice Location Address
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Address Line | 1501 ROBERT J CONLAN BLVD NE STE 7
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City | PALM BAY
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State | FL
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Zip | 32905-3559
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Country | US
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Telephone | 321-372-6897
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Fax | 321-372-6896
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Provider Business Mailing Address
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Address Line | 1501 ROBERT J CONLAN BLVD NE STE 7
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City | PALM BAY
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State | FL
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Zip | 32905-3559
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Country | US
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Telephone | 321-372-6897
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Fax | 321-372-6896
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Authorized Official
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Title or Position | CEO/CLINCIAL DIRECTOR
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Name | MORGAN O'SHAUGHNESSY
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Credential | LMHC
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Telephone | 321-372-6897
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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