Provider Demographics
NPI:1215024781
Name:DANNER, CARRIE EIZENGA (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:EIZENGA
Last Name:DANNER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:10299 TANGLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-7453
Mailing Address - Country:US
Mailing Address - Phone:573-221-2111
Mailing Address - Fax:573-221-2597
Practice Address - Street 1:1221 BROADWAY
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-4005
Practice Address - Country:US
Practice Address - Phone:573-221-2111
Practice Address - Fax:573-221-2597
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040133771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498318625Medicaid