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General NPI Number Information
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NPI Number | 1922388909
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Entity Type | Organization
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Legal Business Name | BAYSIDE PSYCHOLOGY SERVICES, LLC
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Dates
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Enumeration Date | 08/23/2011
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Last Update Date | 08/23/2011
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Provider Practice Location Address
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Address Line | 4400 E HIGHWAY 20 STE 305
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City | NICEVILLE
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State | FL
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Zip | 32578-8779
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Country | US
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Telephone | 850-279-6750
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Fax | 850-279-6752
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Provider Business Mailing Address
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Address Line | 4400 E HIGHWAY 20 STE 305
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City | NICEVILLE
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State | FL
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Zip | 32578-8779
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Country | US
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Telephone | 850-279-6750
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Fax | 850-279-6752
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST / PRESIDENT
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Name | DR. GRETCHEN CHAPMAN TYLER
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Credential | PH.D.
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Telephone | 850-279-6750
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 5264
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License Number State | FL
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