Provider Demographics
NPI:1437404159
Name:NORTHSIDE MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:NORTHSIDE MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-977-8700
Mailing Address - Street 1:12512 BRUCE B DOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9209
Mailing Address - Country:US
Mailing Address - Phone:813-977-8700
Mailing Address - Fax:813-975-8138
Practice Address - Street 1:12512 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9209
Practice Address - Country:US
Practice Address - Phone:813-977-8700
Practice Address - Fax:813-975-8138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)