Provider Demographics
NPI:1841405719
Name:MESA, ELIZABETH DOMINIQUE (PSYD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:DOMINIQUE
Last Name:MESA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4945 SW 140TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-4813
Mailing Address - Country:US
Mailing Address - Phone:305-527-6006
Mailing Address - Fax:
Practice Address - Street 1:19000 SW 377TH ST
Practice Address - Street 2:
Practice Address - City:FLORIDA CITY
Practice Address - State:FL
Practice Address - Zip Code:33034-6409
Practice Address - Country:US
Practice Address - Phone:305-242-1848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7372103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical