1922562628 NPI number — BLUEWATER BEHAVIORAL HEALTH INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922562628 NPI number — BLUEWATER BEHAVIORAL HEALTH INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEWATER BEHAVIORAL HEALTH 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:
1922562628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4515 PARKVIEW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NICEVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32578-8734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-930-4667
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 E HIGHWAY 20 STE 313
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NICEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32578-7700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-520-1230
Provider Business Practice Location Address Fax Number:
773-492-8765
Provider Enumeration Date:
01/27/2019

Additional Information

Authorized Official

Authorized Official Last Name:
POWERS
Authorized Official First Name:
LEIGH
Authorized Official Middle Name:
GAYLE
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
850-797-2598

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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