Healthcare Provider Details

I. General information

NPI: 1881659183
Provider Name (Legal Business Name): ELISABETH J TUDOR LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA J MOORE LLC

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 KINGSLEY AVE STE 9D
ORANGE PARK FL
32073-4580
US

IV. Provider business mailing address

1409 KINGSLEY AVE STE 9D
ORANGE PARK FL
32073-4580
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-2931
  • Fax: 904-212-2969
Mailing address:
  • Phone: 904-269-2931
  • Fax: 904-212-2969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH0002430
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: