MEDICARE: LAKE PSYCHOEDUCATIONAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH5773	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417341488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE PSYCHOEDUCATIONAL CENTER

Provider Business Mailing Address
First Line	:	600 N HIGHWAY 27 STE 1
Second Line	:
City	:	MINNEOLA
State	:	FL
Zip	:	34715-6265
Country	:	US
Telephone Number	:	407-209-7492
Fax Number	:	352-241-8372

Provider Business Practice Location Address
First Line	:	600 N HIGHWAY 27 STE 1
Second Line	:
City	:	MINNEOLA
State	:	FL
Zip	:	34715-6265
Country	:	US
Telephone Number	:	407-209-7492
Fax Number	:	352-241-8372

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GRACE PENA
Credential	:	PSY.D, LMHC
Telephone Number	:	407-209-7492

Provider Enumeration Date	:	03/26/2015
Last Update Date	:	03/26/2015

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Directions to “LAKE PSYCHOEDUCATIONAL CENTER ” Practice Location

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