1770891715 NPI number — BAY HARBOR BEHAVIORAL ASSOCIATES INC.

Table of content: (NPI 1770891715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770891715 NPI number — BAY HARBOR BEHAVIORAL ASSOCIATES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAY HARBOR BEHAVIORAL ASSOCIATES INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770891715
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
930 SNELL ISLE BLVD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33704-3830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-743-3483
Provider Business Mailing Address Fax Number:
727-896-7272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 SNELL ISLE BLVD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33704-3830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-743-3483
Provider Business Practice Location Address Fax Number:
727-896-7272
Provider Enumeration Date:
09/23/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GEDAJLOVIC
Authorized Official First Name:
SARA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
727-743-3483

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH 3061 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103K00000X , with the licence number: MH 3061 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 761456096 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 761456098 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 761456000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".