Provider Demographics
NPI:1326107426
Name:BLAKE, ELIZABETH WINTON (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:WINTON
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 MIDDLE RIVER DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3559
Mailing Address - Country:US
Mailing Address - Phone:954-763-6557
Mailing Address - Fax:954-561-8331
Practice Address - Street 1:915 MIDDLE RIVER DR
Practice Address - Street 2:SUITE 204
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3559
Practice Address - Country:US
Practice Address - Phone:954-763-6557
Practice Address - Fax:954-561-8331
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4139103T00000X
FLRN764412163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL098581OtherVALUE OPTIONS
FL4278424OtherAETNA
FL299483OtherAVMED HEALTH PLANS
FL73460OtherBLUE CROSS BLUE SHIELD
FL084337OtherMANAGED HEALTH NETWORK
FLBLAKELIZOtherCORPHEALTH
FLIPO41451OtherMAGELLAN BEHAVIORAL HEALT
FL6110620OtherUNITED BEHAVIORAL HEALTH
FL098581OtherVALUE OPTIONS