Provider Demographics
NPI:1730953308
Name:BAYSIDE BREAKTHROUGH PSYCHOLOGY
Entity type:Organization
Organization Name:BAYSIDE BREAKTHROUGH PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BIONDOLETTI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:305-393-2574
Mailing Address - Street 1:5011 CHANCELLOR ST NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-3305
Mailing Address - Country:US
Mailing Address - Phone:305-393-2574
Mailing Address - Fax:
Practice Address - Street 1:5011 CHANCELLOR ST NE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-3305
Practice Address - Country:US
Practice Address - Phone:305-393-2574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-14
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health