Provider Demographics
NPI:1518910116
Name:SHADDEN, ELIZABETH BURTY (LMHC)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:BURTY
Last Name:SHADDEN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MS
Other - First Name:MARTHA
Other - Middle Name:ELIZABETH
Other - Last Name:BURTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHC
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJP PSYCHIATRIC
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-3688
Practice Address - Fax:904-244-3455
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH789101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health