Provider Demographics
NPI:1841778636
Name:BAYOU WELLNESS OF NORTHWEST FLORIDA, LLC
Entity Type:Organization
Organization Name:BAYOU WELLNESS OF NORTHWEST FLORIDA, LLC
Other - Org Name:BAYOU WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:COUNSELOR, OWNER
Authorized Official - Prefix:
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 1:17 W MAXWELL ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-1717
Mailing Address - Country:US
Mailing Address - Phone:850-324-7912
Mailing Address - Fax:850-270-7821
Practice Address - Street 1:17 W MAXWELL ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1717
Practice Address - Country:US
Practice Address - Phone:850-324-7912
Practice Address - Fax:850-270-7821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12035101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty