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General NPI Number Information
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NPI Number | 1861026569
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Entity Type | Organization
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Legal Business Name | GULFSIDE PSYCHOLOGY INC
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Dates
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Enumeration Date | 03/03/2020
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Last Update Date | 08/05/2020
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Provider Practice Location Address
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Address Line | 3902 E STATE ROAD 64
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City | BRADENTON
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State | FL
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Zip | 34208-9059
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Country | US
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Telephone | 941-243-3005
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Fax | 941-739-9358
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Provider Business Mailing Address
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Address Line | 5614 CLOVERLEAF RUN
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City | BRADENTON
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State | FL
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Zip | 34211-4048
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Country | US
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Telephone | 860-250-4488
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Fax | 941-739-9358
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JOHN K MCDERMOTT
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Credential | OWNER
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Telephone | 941-243-3005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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