Provider Demographics
NPI:1306184239
Name:BAYCARE BEHAVIORAL HEALTH INC.
Entity Type:Organization
Organization Name:BAYCARE BEHAVIORAL HEALTH INC.
Other - Org Name:COUNTRYSIDE - PRIMARY CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-281-9390
Mailing Address - Street 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-281-9390
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:2461 ENTERPRISE RD
Practice Address - Street 2:SUITE C
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33763-1726
Practice Address - Country:US
Practice Address - Phone:727-726-3785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-28
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid
FLPENDINGMedicaid