Provider Demographics
NPI:1891203485
Name:HEALTHY LIFESTYLES TAMPA BAY LLC
Entity Type:Organization
Organization Name:HEALTHY LIFESTYLES TAMPA BAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:QUINLAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:727-906-6185
Mailing Address - Street 1:8479 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-3503
Mailing Address - Country:US
Mailing Address - Phone:727-906-6185
Mailing Address - Fax:866-352-2359
Practice Address - Street 1:8479 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702
Practice Address - Country:US
Practice Address - Phone:727-906-6185
Practice Address - Fax:866-352-2359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7593103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPY7593OtherPROFESSIONAL LICENSE
FLPY7593OtherLICENSE