Provider Demographics
NPI:1881659183
Name:TUDOR, ELISABETH J (LMHC)
Entity type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:J
Last Name:TUDOR
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:J
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LLC
Mailing Address - Street 1:1409 KINGSLEY AVE STE 9D
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4580
Mailing Address - Country:US
Mailing Address - Phone:904-269-2931
Mailing Address - Fax:904-212-2969
Practice Address - Street 1:1409 KINGSLEY AVE STE 9D
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4580
Practice Address - Country:US
Practice Address - Phone:904-269-2931
Practice Address - Fax:904-212-2969
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH0002430101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL195812Medicare UPIN
FLZ3298Medicare UPIN