Provider Demographics
NPI:1407416514
Name:FRAZIER, ELZIE DWIGHT
Entity Type:Individual
Prefix:
First Name:ELZIE
Middle Name:DWIGHT
Last Name:FRAZIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 CODY CALEB DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-2206
Mailing Address - Country:US
Mailing Address - Phone:863-670-8631
Mailing Address - Fax:
Practice Address - Street 1:526 CODY CALEB DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-2206
Practice Address - Country:US
Practice Address - Phone:863-670-8631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251B00000XAgenciesCase Management