Provider Demographics
NPI:1417341488
Name:LAKE PSYCHOEDUCATIONAL CENTER
Entity Type:Organization
Organization Name:LAKE PSYCHOEDUCATIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LMHC
Authorized Official - Phone:407-209-7492
Mailing Address - Street 1:600 N HIGHWAY 27 STE 1
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34715-6265
Mailing Address - Country:US
Mailing Address - Phone:407-209-7492
Mailing Address - Fax:352-241-8372
Practice Address - Street 1:600 N HIGHWAY 27 STE 1
Practice Address - Street 2:
Practice Address - City:MINNEOLA
Practice Address - State:FL
Practice Address - Zip Code:34715-6265
Practice Address - Country:US
Practice Address - Phone:407-209-7492
Practice Address - Fax:352-241-8372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5773101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL762627400Medicaid