Provider Demographics
NPI:1083096036
Name:BAYOU WELLNESS, LLC
Entity Type:Organization
Organization Name:BAYOU WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKS
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:850-324-7912
Mailing Address - Street 1:69 BAY BRIDGE DR
Mailing Address - Street 2:SUITE H
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:69 BAY BRIDGE DR
Practice Address - Street 2:SUITE H
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4468
Practice Address - Country:US
Practice Address - Phone:850-324-7912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12035101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty