Provider Demographics
NPI:1285679902
Name:LAKE MARY PSYCHIATRIC SERVICES LLC
Entity Type:Organization
Organization Name:LAKE MARY PSYCHIATRIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOTA-CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-330-5818
Mailing Address - Street 1:101 TIMBERLACHEN CIR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6124
Mailing Address - Country:US
Mailing Address - Phone:407-330-5818
Mailing Address - Fax:407-330-5820
Practice Address - Street 1:101 TIMBERLACHEN CIR
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-6124
Practice Address - Country:US
Practice Address - Phone:407-330-5818
Practice Address - Fax:407-330-5820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-82747174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7771009OtherAETNA
FL111973343307OtherMENTAL HEALTH NETWORK
FL272693OtherHARMONY BEHAVIORAL HEALTH
FL52339OtherBLUE CROSS BLUE SHIELD
FL543580OtherVALUE OPTIONS
FL110962OtherAMERIGROUP
FL110962OtherAMERIGROUP
FL52339OtherBLUE CROSS BLUE SHIELD
FL111973343307OtherMENTAL HEALTH NETWORK
FL=========OtherMAGELLAN
FL52339OtherBLUE CROSS BLUE SHIELD