Provider Demographics
NPI:1659818979
Name:WANNSTEDT, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WANNSTEDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-3440
Mailing Address - Country:US
Mailing Address - Phone:724-420-3307
Mailing Address - Fax:
Practice Address - Street 1:3904 OLEANDER DR
Practice Address - Street 2:SUITE 102
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6717
Practice Address - Country:US
Practice Address - Phone:910-313-3232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician