MEDICARE: ELIZABETH BLACKBURN

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	1041C0700X	Clinical Social Worker	15819	FL
2	1041C0700X	Clinical Social Worker	SW15819	FL

General Provider Information

NPI Number	:	1356813364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH BLACKBURN

Provider Business Mailing Address
First Line	:	4089 LAKE TAHOE CIR
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-7878
Country	:	US
Telephone Number	:	407-619-5075
Fax Number	:

Provider Business Practice Location Address
First Line	:	4089 LAKE TAHOE CIR
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-7878
Country	:	US
Telephone Number	:	407-619-5075
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2019
Last Update Date	:	06/04/2026

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