Provider Demographics
NPI:1003336462
Name:HART, ELIZABETH IRENE (RBT)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:IRENE
Last Name:HART
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:MRS
Other - First Name:BETH
Other - Middle Name:IRENE
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RBT
Mailing Address - Street 1:305 PINE MOSS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-6307
Mailing Address - Country:US
Mailing Address - Phone:850-496-0155
Mailing Address - Fax:
Practice Address - Street 1:116 4TH ST SE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5425
Practice Address - Country:US
Practice Address - Phone:850-368-9373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-17-35933106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician