Provider Demographics
NPI:1760528210
Name:NANNEMAN, ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:NANNEMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10018 KENNERLY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2106
Mailing Address - Country:US
Mailing Address - Phone:314-525-4422
Mailing Address - Fax:314-525-4420
Practice Address - Street 1:2707 BROWNS LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7213
Practice Address - Country:US
Practice Address - Phone:870-972-4939
Practice Address - Fax:870-972-4911
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2077-C1041C0700X
MO20090030941041C0700X
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical