Provider Demographics
NPI:1104842467
Name:MAGNUS, ELIZABETH C (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:C
Last Name:MAGNUS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0418
Mailing Address - Country:US
Mailing Address - Phone:608-752-7255
Mailing Address - Fax:608-752-6942
Practice Address - Street 1:1519 PRIMROSE LN
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0418
Practice Address - Country:US
Practice Address - Phone:608-752-7255
Practice Address - Fax:608-752-6942
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI604103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39007800Medicaid