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General NPI Number Information
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NPI Number | 1841778636
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Entity Type | Organization
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Legal Business Name | BAYOU WELLNESS OF NORTHWEST FLORIDA, LLC
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Dates
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Enumeration Date | 08/02/2018
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Last Update Date | 12/01/2023
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Provider Practice Location Address
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Address Line | 17 W MAXWELL ST
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City | PENSACOLA
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State | FL
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Zip | 32501-1717
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Country | US
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Telephone | 850-324-7912
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Fax | 850-270-7821
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Provider Business Mailing Address
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Address Line | 17 W MAXWELL ST
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City | PENSACOLA
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State | FL
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Zip | 32501-1717
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Country | US
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Telephone | 850-324-7912
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Fax | 850-270-7821
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Authorized Official
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Title or Position | COUNSELOR, OWNER
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Name | ANDREA BURKS
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Credential | LMHC
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Telephone | 850-324-7912
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | MH12035
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License Number State | FL
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