Provider Demographics
NPI:1699250605
Name:CHAMBERLAIN, ELIZABETH (MA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6324 PANTHER LN APT 9
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-6345
Mailing Address - Country:US
Mailing Address - Phone:239-233-3070
Mailing Address - Fax:
Practice Address - Street 1:5621 STRAND BLVD STE 109
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-7302
Practice Address - Country:US
Practice Address - Phone:239-336-4846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH17513101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIMH17513OtherREGISTERED MENTAL HEALTH COUNSELOR INTERN NUMBER