Provider Demographics
NPI:1477532166
Name:MARKS, ELIZABETH RISCH (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RISCH
Last Name:MARKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:LYNNE
Other - Last Name:RISCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:100 SERVAIS WAY
Mailing Address - Street 2:BLDG 90531
Mailing Address - City:HURLBURT FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32544
Mailing Address - Country:US
Mailing Address - Phone:850-884-2174
Mailing Address - Fax:
Practice Address - Street 1:100 SERVAIS WAY
Practice Address - Street 2:BUILDING 90531
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-1391
Practice Address - Country:US
Practice Address - Phone:850-884-2174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000072511041C0700X
FLSW87061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVAD000Medicare UPIN