Provider Demographics
NPI:1972788669
Name:HARBORSIDE PSYCHIATRIC SERVICES, LLC
Entity Type:Organization
Organization Name:HARBORSIDE PSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:941-205-3333
Mailing Address - Street 1:150 W. MCKENZIE STREET
Mailing Address - Street 2:SUITE #117
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-5500
Mailing Address - Country:US
Mailing Address - Phone:941-205-3333
Mailing Address - Fax:941-205-3334
Practice Address - Street 1:150 W. MCKENZIE STREET
Practice Address - Street 2:SUITE #117
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950
Practice Address - Country:US
Practice Address - Phone:941-205-3333
Practice Address - Fax:941-205-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-01
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW77831041C0700X
FLL070001249242084N0400X, 2084P0800X
FLME865472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266691001Medicaid
B84265Medicare PIN
FL57795AMedicare PIN