Provider Demographics
NPI:1609931955
Name:JOEL B FREID PHD PA
Entity Type:Organization
Organization Name:JOEL B FREID PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:FREID
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:863-644-0506
Mailing Address - Street 1:5925 IMPERIAL PKWY
Mailing Address - Street 2:SUITE 128
Mailing Address - City:MULBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:33860-8476
Mailing Address - Country:US
Mailing Address - Phone:863-644-0506
Mailing Address - Fax:863-644-7522
Practice Address - Street 1:2020 W LAKE PARKER DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-5005
Practice Address - Country:US
Practice Address - Phone:863-682-7580
Practice Address - Fax:863-683-9564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 0002213103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1346350600OtherINDIVIDUAL NPI
FL74164Medicare ID - Type UnspecifiedINDIVIDUAL