=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912576695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BYWATER MENTAL HEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2021
-----------------------------------------------------
Last Update Date | 06/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10225 ULMERTON RD STE 3A
-----------------------------------------------------
City | LARGO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33771-3519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-371-0079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10225 ULMERTON RD STE 3A
-----------------------------------------------------
City | LARGO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33771-3519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-371-0079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GERALD LEE RANDALL
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 727-371-0079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------