MEDICARE: DR. ELIZABETH WINTON BLAKE PH.D.

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
2	163W00000X	Registered Nurse	RN764412	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	098581	OTHER	FL	VALUE OPTIONS
2	4278424	OTHER	FL	AETNA
3	299483	OTHER	FL	AVMED HEALTH PLANS
4	73460	OTHER	FL	BLUE CROSS BLUE SHIELD
5	084337	OTHER	FL	MANAGED HEALTH NETWORK
6	BLAKELIZ	OTHER	FL	CORPHEALTH
7	IPO41451	OTHER	FL	MAGELLAN BEHAVIORAL HEALT
8	6110620	OTHER	FL	UNITED BEHAVIORAL HEALTH

General Provider Information

NPI Number	:	1326107426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH WINTON BLAKE PH.D.

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	11/18/2010

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Directions to “ DR. ELIZABETH WINTON BLAKE PH.D.” Practice Location

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