Provider Demographics
NPI:1790544658
Name:LAKE NEURODIVERSITY, LLC
Entity Type:Organization
Organization Name:LAKE NEURODIVERSITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:352-348-6989
Mailing Address - Street 1:711 W MAIN ST STE 127
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5128
Mailing Address - Country:US
Mailing Address - Phone:352-460-1925
Mailing Address - Fax:
Practice Address - Street 1:711 W MAIN ST STE 127
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5128
Practice Address - Country:US
Practice Address - Phone:352-460-1925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty