MEDICARE: DR. ELIZABETH DOMINIQUE MESA PSYD

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	103TC0700X	Clinical Psychologist	PY7372	FL

General Provider Information

NPI Number	:	1841405719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH DOMINIQUE MESA PSYD

Provider Business Mailing Address
First Line	:	4945 SW 140TH CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-4813
Country	:	US
Telephone Number	:	305-527-6006
Fax Number	:

Provider Business Practice Location Address
First Line	:	19000 SW 377TH ST
Second Line	:
City	:	FLORIDA CITY
State	:	FL
Zip	:	33034-6409
Country	:	US
Telephone Number	:	305-242-1848
Fax Number	:

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

Provider Enumeration Date	:	05/13/2007
Last Update Date	:	07/08/2007

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