Provider Demographics
NPI:1255740767
Name:PSYCHIATRIC ASSOCIATES. P.A.
Entity type:Organization
Organization Name:PSYCHIATRIC ASSOCIATES. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY, PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LANAH
Authorized Official - Middle Name:W
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:904-264-6977
Mailing Address - Street 1:1543 KINGSLEY AVE STE 14
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4570
Mailing Address - Country:US
Mailing Address - Phone:904-264-6977
Mailing Address - Fax:904-269-0870
Practice Address - Street 1:1543 KINGSLEY AVE STE 14
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4570
Practice Address - Country:US
Practice Address - Phone:904-264-6977
Practice Address - Fax:904-269-0870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25939900Medicaid
FL25939900Medicaid