NPIMap

Organization Active NPI

Peace River Center for Personal Development Inc

  • Psychiatry Physician
  • Lakeland, FL
National Provider Identifier
1114673589
Registry record updated May 24, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
PEACE RIVER CENTER FOR PERSONAL DEVELOPMENT INC
Practice address
230 S Lake Parker Ave
Lakeland, FL 33801-5742
Phone
(863) 519-0575
Fax
(863) 582-9251
NPI assigned
Feb 24, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 24, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jo Deck, BA, CPC
Title
Credentialing Specialist
Phone
(863) 519-0575

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X Primary

Addresses

Primary practice location

230 S Lake Parker Ave
Lakeland, FL 33801-5742

Mailing address

PO Box 1559
Bartow, FL 33831-1559
Phone (863) 519-0575

Other identifiers 1

IdentifierTypeStateIssuer
060310423MedicaidFL

Other names 1

  • Peace River Center Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Peace River Center for14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

Organizations that report the same tax identification number in the National Provider Directory.

View all 13

Practitioners & affiliated clinicians

Practitioners 22

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 22

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1645660800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1684886400000",
    "number": "1114673589",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1559",
            "city": "BARTOW",
            "state": "FL",
            "postal_code": "338311559",
            "telephone_number": "863-519-0575",
            "fax_number": "863-582-9251"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "230 S LAKE PARKER AVE",
            "city": "LAKELAND",
            "state": "FL",
            "postal_code": "338015742",
            "telephone_number": "863-519-0575",
            "fax_number": "863-582-9251"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEACE RIVER CENTER FOR PERSONAL DEVELOPMENT INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-02-24",
        "last_updated": "2023-05-24",
        "certification_date": "2023-05-24",
        "status": "A",
        "authorized_official_last_name": "DECK",
        "authorized_official_first_name": "JO",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "863-519-0575",
        "authorized_official_credential": "BA, CPC"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "060310423",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Peace River Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Peace River Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lakeland, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 24, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.