Provider Demographics
NPI:1629057849
Name:WAGNER, ELIZABETH WELDER (LISW)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:WELDER
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:WELDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:1217 K AVE
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:IA
Mailing Address - Zip Code:50201-1943
Mailing Address - Country:US
Mailing Address - Phone:515-382-4099
Mailing Address - Fax:
Practice Address - Street 1:3600 LINCOLN WAY
Practice Address - Street 2:SUITE 4
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50014-7595
Practice Address - Country:US
Practice Address - Phone:515-239-4410
Practice Address - Fax:515-663-4885
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA047011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA36323OtherBLUE SHIELD OF IOWA
IA36323OtherBLUE SHIELD OF IOWA