=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326107426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH WINTON BLAKE PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 11/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 MIDDLE RIVER DR SUITE 204
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33304-3559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-763-6557
-----------------------------------------------------
Fax | 954-561-8331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 915 MIDDLE RIVER DR SUITE 204
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33304-3559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-763-6557
-----------------------------------------------------
Fax | 954-561-8331
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY4139
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN764412
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------