MEDICARE: FORT LAUDERDALE COUNSELING SERVICES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PY4139	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	084337	OTHER	FL	MANAGED HEALTH NETWORK
2	4278424	OTHER	FL	AETNA
3	098581	OTHER	FL	VALUE OPTIONS
4	6110620	OTHER	FL	UNITED BEHAVIORAL HEALTH
5	73460	OTHER	FL	BLUE CROSS BLUE SHIELD
6	BLAKELIZ	OTHER	FL	CORPHEALTH
7	IPO41451	OTHER		MAGELLAN BEHAVIORAL HEALT

General Provider Information

NPI Number	:	1154592970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT LAUDERDALE COUNSELING SERVICES, INC

Provider Business Mailing Address
First Line	:	915 MIDDLE RIVER DR
Second Line	:	SUITE 204
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3559
Country	:	US
Telephone Number	:	954-763-6557
Fax Number	:	954-561-8331

Provider Business Practice Location Address
First Line	:	915 MIDDLE RIVER DR
Second Line	:	SUITE 204
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3559
Country	:	US
Telephone Number	:	954-763-6557
Fax Number	:	954-561-8331

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ELIZABETH W BLAKE
Credential	:	PHD
Telephone Number	:	954-763-6557

Provider Enumeration Date	:	03/19/2008
Last Update Date	:	02/25/2013

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Directions to “FORT LAUDERDALE COUNSELING SERVICES, INC ” Practice Location

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