=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871317586
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHT BAY PSYCHIATRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2024
-----------------------------------------------------
Last Update Date | 11/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3502 HENDERSON BLVD STE 312
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33609-4087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-537-8804
-----------------------------------------------------
Fax | 813-537-8804
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8207 WATER TOWER DR
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33619-6624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-334-5700
-----------------------------------------------------
Fax | 813-537-3809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PMHNP-BC
-----------------------------------------------------
Name | PEYTON BRUNSWICK
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 813-334-5700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------