Healthcare Provider Details

I. General information

NPI: 1043546922
Provider Name (Legal Business Name): SERENITY OF CENTRAL FLORIDA P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 W DIXIE AVE
LEESBURG FL
34748-6312
US

IV. Provider business mailing address

PO BOX 1840
LADY LAKE FL
32158-1840
US

V. Phone/Fax

Practice location:
  • Phone: 352-577-8197
  • Fax: 352-577-8741
Mailing address:
  • Phone: 352-577-8197
  • Fax: 352-577-8741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberME 96757
License Number StateFL

VIII. Authorized Official

Name: YASIN CHOUDRY
Title or Position: OWNER
Credential: MD
Phone: 352-577-8197