MEDICARE: ELZIE DWIGHT FRAZIER

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	251B00000X	Case Management Agency
2	101YM0800X	Mental Health Counselor		FL

General Provider Information

NPI Number	:	1407416514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELZIE DWIGHT FRAZIER

Provider Business Mailing Address
First Line	:	526 CODY CALEB DR
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-2206
Country	:	US
Telephone Number	:	863-670-8631
Fax Number	:

Provider Business Practice Location Address
First Line	:	526 CODY CALEB DR
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-2206
Country	:	US
Telephone Number	:	863-670-8631
Fax Number	:

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

Provider Enumeration Date	:	06/20/2019
Last Update Date	:	07/15/2019

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