MEDICARE: CHILD & ADULT PSYCHIATRY OF LAKEWOOD RANCH

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1942653704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILD & ADULT PSYCHIATRY OF LAKEWOOD RANCH

Provider Business Mailing Address
First Line	:	5331 PAYLOR LN
Second Line	:	SUITE 200
City	:	LAKEWOOD RANCH
State	:	FL
Zip	:	34240-2209
Country	:	US
Telephone Number	:	941-518-1265
Fax Number	:

Provider Business Practice Location Address
First Line	:	5331 PAYLOR LN
Second Line	:	SUITE 200
City	:	LAKEWOOD RANCH
State	:	FL
Zip	:	34240-2209
Country	:	US
Telephone Number	:	941-518-1265
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JESSICA COLLAZO
Credential	:
Telephone Number	:	941-518-1265

Provider Enumeration Date	:	07/18/2016
Last Update Date	:	07/18/2016

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