Provider Demographics
NPI:1255492526
Name:PRUDENTI, ELIZABETH C (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:C
Last Name:PRUDENTI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 US HIGHWAY 1
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-1612
Mailing Address - Country:US
Mailing Address - Phone:772-589-7680
Mailing Address - Fax:772-589-9294
Practice Address - Street 1:1515 US HIGHWAY 1
Practice Address - Street 2:SUITE 201
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-1612
Practice Address - Country:US
Practice Address - Phone:772-589-7680
Practice Address - Fax:772-589-9294
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL64461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6446OtherLCSW