Provider Demographics
NPI:1154592970
Name:FORT LAUDERDALE COUNSELING SERVICES, INC
Entity type:Organization
Organization Name:FORT LAUDERDALE COUNSELING SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:954-763-6557
Mailing Address - Street 1:915 MIDDLE RIVER DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3559
Mailing Address - Country:US
Mailing Address - Phone:954-763-6557
Mailing Address - Fax:954-561-8331
Practice Address - Street 1:915 MIDDLE RIVER DR
Practice Address - Street 2:SUITE 204
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3559
Practice Address - Country:US
Practice Address - Phone:954-763-6557
Practice Address - Fax:954-561-8331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4139103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084337OtherMANAGED HEALTH NETWORK
FL4278424OtherAETNA
FL098581OtherVALUE OPTIONS
FL6110620OtherUNITED BEHAVIORAL HEALTH
FL73460OtherBLUE CROSS BLUE SHIELD
FLBLAKELIZOtherCORPHEALTH
IPO41451OtherMAGELLAN BEHAVIORAL HEALT
FL098581OtherVALUE OPTIONS