NPIMap

Organization Active NPI

Southern Psychiatry LLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Crestview, FL
National Provider Identifier
1467917898
Registry record updated Dec 15, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X
Legal business name
SOUTHERN PSYCHIATRY LLC
Practice address
500 Hospital Dr
Crestview, FL 32539-7355
Phone
(850) 687-0887
NPI assigned
Feb 11, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 15, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Renee McCormack, APRNNPI 1114292992
Title
Owner
Phone
(850) 687-0887

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X Primary
Primary Care Nurse PractitionerGroup: 193400000X SINGLE SPECIALTY GROUP 363LP2300X

Addresses

Primary practice location

500 Hospital Dr
Crestview, FL 32539-7355

Mailing address

201 N Blue Heron Dr
Santa Rosa Beach, FL 32459-3039
Phone (850) 687-0887

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190228000472 FL Part B Supplier - Clinic/Group Practice 0749529261 Receives reassigned benefits from 6 practitioners
Practice locations: Santa Rosa Beach, FL

National Provider Directory

National Provider Directory

Locations

3906 US Highway 98 W
#1522
Santa Rsa Bch, FL 32459

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1549843200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1671062400000",
    "number": "1467917898",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "201 N BLUE HERON DR",
            "city": "SANTA ROSA BEACH",
            "state": "FL",
            "postal_code": "324593039",
            "telephone_number": "850-687-0887"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 HOSPITAL DR",
            "city": "CRESTVIEW",
            "state": "FL",
            "postal_code": "325397355",
            "telephone_number": "850-687-0887"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN PSYCHIATRY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-02-11",
        "last_updated": "2022-12-15",
        "certification_date": "2022-12-15",
        "status": "A",
        "authorized_official_last_name": "MCCORMACK",
        "authorized_official_first_name": "RENEE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "850-687-0887",
        "authorized_official_credential": "APRN"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LP2300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Crestview, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.