Provider Demographics
NPI:1285270512
Name:WAGNER, ELIZABETH CLAIR
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CLAIR
Last Name:WAGNER
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 1:8915 WILKENSEN RD SE TRLR 7B
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-9782
Mailing Address - Country:US
Mailing Address - Phone:505-419-7118
Mailing Address - Fax:
Practice Address - Street 1:8815 S TACOMA WAY STE 122
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-7011
Practice Address - Country:US
Practice Address - Phone:206-388-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician