Provider Demographics
NPI:1043785926
Name:BAYSIDE NEUROTHERAPY, LLC
Entity type:Organization
Organization Name:BAYSIDE NEUROTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LP
Authorized Official - Phone:850-541-8520
Mailing Address - Street 1:1022 W 23RD ST STE 530
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3688
Mailing Address - Country:US
Mailing Address - Phone:850-541-8520
Mailing Address - Fax:850-541-9928
Practice Address - Street 1:1022 W 23RD ST STE 530
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3688
Practice Address - Country:US
Practice Address - Phone:850-541-8520
Practice Address - Fax:850-541-9928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)