Provider Demographics
NPI:1578748976
Name:WOLD, ELIZABETH MARIE (LMHC, CRC, CAP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MARIE
Last Name:WOLD
Suffix:
Gender:F
Credentials:LMHC, CRC, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 BAYMEADOWS WAY
Mailing Address - Street 2:SUITE 120B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7557
Mailing Address - Country:US
Mailing Address - Phone:904-731-0565
Mailing Address - Fax:
Practice Address - Street 1:7825 BAYMEADOWS WAY
Practice Address - Street 2:SUITE 120B
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7557
Practice Address - Country:US
Practice Address - Phone:904-731-0565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6765101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7678444-00Medicaid
FL0760706-00Medicaid