Provider Demographics
NPI:1063919637
Name:PEACE OF MIND--BEACHSIDE
Entity type:Organization
Organization Name:PEACE OF MIND--BEACHSIDE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:386-262-5197
Mailing Address - Street 1:198 VINING CT # 5
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-6658
Mailing Address - Country:US
Mailing Address - Phone:386-256-5553
Mailing Address - Fax:386-256-5553
Practice Address - Street 1:198 VINING CT # 5
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-6658
Practice Address - Country:US
Practice Address - Phone:386-256-5553
Practice Address - Fax:386-256-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9355262363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL696567Medicaid