Provider Demographics
NPI:1669498002
Name:NORTHSIDE BEHAVIORAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:NORTHSIDE BEHAVIORAL HEALTH CENTER, INC.
Other - Org Name:NORTHSIDE MENTAL HEALTH CTR, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-281-9202
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:727-315-6974
Mailing Address - Fax:813-635-2613
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
Practice Address - Country:US
Practice Address - Phone:813-977-8700
Practice Address - Fax:813-971-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117042300Medicaid
FL060370800Medicaid