Provider Demographics
NPI:1861026569
Name:GULFSIDE PSYCHOLOGY INC
Entity Type:Organization
Organization Name:GULFSIDE PSYCHOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:941-243-3005
Mailing Address - Street 1:5614 CLOVERLEAF RUN
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-4048
Mailing Address - Country:US
Mailing Address - Phone:860-250-4488
Mailing Address - Fax:941-739-9358
Practice Address - Street 1:3902 E STATE ROAD 64
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-9059
Practice Address - Country:US
Practice Address - Phone:941-243-3005
Practice Address - Fax:941-739-9358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-03
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty