Provider Demographics
NPI:1033472667
Name:NORTHSIDE MENTAL HEALTH CENTER
Entity type:Organization
Organization Name:NORTHSIDE MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR THERAPIST/LMHC
Authorized Official - Prefix:
Authorized Official - First Name:CRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ-SCALZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-977-8700
Mailing Address - Street 1:12512 BRUCE B DOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12512 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9209
Practice Address - Country:US
Practice Address - Phone:813-977-8700
Practice Address - Fax:813-975-8138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11041251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health