Provider Demographics
NPI:1518020775
Name:PSYCHIATRIC PROFESSIONAL SERVICES PA
Entity Type:Organization
Organization Name:PSYCHIATRIC PROFESSIONAL SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:BLANKEMEIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-629-6440
Mailing Address - Street 1:2180 N PARK AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2358
Mailing Address - Country:US
Mailing Address - Phone:407-629-6440
Mailing Address - Fax:407-629-5766
Practice Address - Street 1:2180 N PARK AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2358
Practice Address - Country:US
Practice Address - Phone:407-629-6440
Practice Address - Fax:407-629-5766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00506312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty