Provider Demographics
NPI:1124456587
Name:LAKE MARY PSYCHIATRY AND COUNSELING LLC
Entity type:Organization
Organization Name:LAKE MARY PSYCHIATRY AND COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:KROTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-324-0405
Mailing Address - Street 1:PO BOX 951468
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32795-1468
Mailing Address - Country:US
Mailing Address - Phone:407-324-0405
Mailing Address - Fax:407-324-0075
Practice Address - Street 1:305 WAYMONT CT
Practice Address - Street 2:STE 111
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3566
Practice Address - Country:US
Practice Address - Phone:407-324-0405
Practice Address - Fax:407-324-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS49852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056251300Medicaid
066470OtherVALUE OPTIONS
E34825Medicare UPIN
FL056251300Medicaid