Provider Demographics
NPI:1336379130
Name:PANKRATZ, ELOISE J (LSCSW)
Entity Type:Individual
Prefix:
First Name:ELOISE
Middle Name:J
Last Name:PANKRATZ
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 S. GOVERNEOUR RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207
Mailing Address - Country:US
Mailing Address - Phone:316-772-2000
Mailing Address - Fax:
Practice Address - Street 1:240 N ROCK RD
Practice Address - Street 2:STE 228
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2245
Practice Address - Country:US
Practice Address - Phone:316-351-8029
Practice Address - Fax:316-776-4547
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS7357104100000X
KS46651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker