Provider Demographics
NPI:1851998595
Name:MAGNUSON, ELIZABETH ANN (BA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:MAGNUSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 N HIGHWAY 101 STE 204
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:OR
Mailing Address - Zip Code:97146-9371
Mailing Address - Country:US
Mailing Address - Phone:503-325-5722
Mailing Address - Fax:
Practice Address - Street 1:486 12TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4122
Practice Address - Country:US
Practice Address - Phone:503-325-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WACG61112066101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2165787Medicaid