Provider Demographics
NPI:1881178663
Name:WANGRUD, LISA ANN (LMSW)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:WANGRUD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:BOGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2201 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-2123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 LUDINGTON ST STE 303
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-3500
Practice Address - Country:US
Practice Address - Phone:906-553-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801087887104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical