Provider Demographics
NPI:1225400773
Name:LOVE, ELIZABETH WIYGUL (EDS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:WIYGUL
Last Name:LOVE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-4023
Mailing Address - Country:US
Mailing Address - Phone:515-739-2722
Mailing Address - Fax:151-739-2205
Practice Address - Street 1:18 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-4023
Practice Address - Country:US
Practice Address - Phone:515-739-2722
Practice Address - Fax:151-739-2205
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM370136101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool