Healthcare Provider Details

I. General information

NPI: 1417341488
Provider Name (Legal Business Name): LAKE PSYCHOEDUCATIONAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N HIGHWAY 27 STE 1
MINNEOLA FL
34715-6265
US

IV. Provider business mailing address

600 N HIGHWAY 27 STE 1
MINNEOLA FL
34715-6265
US

V. Phone/Fax

Practice location:
  • Phone: 407-209-7492
  • Fax: 352-241-8372
Mailing address:
  • Phone: 407-209-7492
  • Fax: 352-241-8372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH5773
License Number StateFL

VIII. Authorized Official

Name: GRACE PENA
Title or Position: PRESIDENT
Credential: PSY.D, LMHC
Phone: 407-209-7492