MEDICARE: LONGSHORE PSYCHIATRIC AND MENTAL HEALTH SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1689544512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGSHORE PSYCHIATRIC AND MENTAL HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	23 MAIN ST STE 103
Second Line	:
City	:	HILTON HEAD ISLAND
State	:	SC
Zip	:	29926-6607
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	23 MAIN ST STE 103
Second Line	:
City	:	HILTON HEAD ISLAND
State	:	SC
Zip	:	29926-6607
Country	:	US
Telephone Number	:	813-997-2099
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	BRIAN CLUKIE
Credential	:
Telephone Number	:	813-997-2099

Provider Enumeration Date	:	11/06/2025
Last Update Date	:	03/10/2026

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