Provider Demographics
NPI:1750468096
Name:KIEBZAK, ELIZABETH S (LCSW, CAP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:S
Last Name:KIEBZAK
Suffix:
Gender:F
Credentials:LCSW, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 FREEMONT ST S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2446
Mailing Address - Country:US
Mailing Address - Phone:727-424-5323
Mailing Address - Fax:
Practice Address - Street 1:5122 GULFPORT BLVD S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-4922
Practice Address - Country:US
Practice Address - Phone:727-322-6149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3017101YA0400X
FLSW7488101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health