Provider Demographics
NPI:1922388909
Name:BAYSIDE PSYCHOLOGY SERVICES, LLC
Entity Type:Organization
Organization Name:BAYSIDE PSYCHOLOGY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:CHAPMAN
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:850-279-6750
Mailing Address - Street 1:4400 E HIGHWAY 20
Mailing Address - Street 2:STE 305
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8779
Mailing Address - Country:US
Mailing Address - Phone:850-279-6750
Mailing Address - Fax:850-279-6752
Practice Address - Street 1:4400 E HIGHWAY 20
Practice Address - Street 2:STE 305
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8779
Practice Address - Country:US
Practice Address - Phone:850-279-6750
Practice Address - Fax:850-279-6752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5264103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45577Medicare UPIN
FL54072WMedicare UPIN