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General NPI Number Information
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NPI Number | 1124456587
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Entity Type | Organization
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Legal Business Name | LAKE MARY PSYCHIATRY AND COUNSELING LLC
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Dates
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Enumeration Date | 10/23/2013
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Last Update Date | 10/23/2013
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Provider Practice Location Address
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Address Line | 305 WAYMONT CT STE 111
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City | LAKE MARY
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State | FL
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Zip | 32746-3566
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Country | US
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Telephone | 407-324-0405
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Fax | 407-324-0075
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Provider Business Mailing Address
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Address Line | PO BOX 951468
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City | LAKE MARY
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State | FL
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Zip | 32795-1468
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Country | US
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Telephone | 407-324-0405
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Fax | 407-324-0075
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JEFFREY KROTENBERG
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Credential | D.O.
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Telephone | 407-324-0405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | OS4985
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License Number State | FL
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