Provider Demographics
NPI:1821798414
Name:BLUE SEA MENTAL HEALTH PRACTITIONERS LLC
Entity type:Organization
Organization Name:BLUE SEA MENTAL HEALTH PRACTITIONERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BAXTER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:386-232-8089
Mailing Address - Street 1:381 PALM COAST PKWY SW UNIT 2
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-4782
Mailing Address - Country:US
Mailing Address - Phone:386-232-8089
Mailing Address - Fax:
Practice Address - Street 1:381 PALM COAST PKWY SW UNIT 2
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4782
Practice Address - Country:US
Practice Address - Phone:386-232-8089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-03
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty