Provider Demographics
NPI:1114642410
Name:BAYSIDE FAMILY COUNSELING LLC
Entity Type:Organization
Organization Name:BAYSIDE FAMILY COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WINGARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-616-5727
Mailing Address - Street 1:1890 HALLENDALE AVE SW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32908-1286
Mailing Address - Country:US
Mailing Address - Phone:321-616-5727
Mailing Address - Fax:
Practice Address - Street 1:1890 HALLENDALE AVE SW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32908-1286
Practice Address - Country:US
Practice Address - Phone:321-616-5727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty