Provider Demographics
NPI:1306062922
Name:WAGNER, ELIZABETH (LCPC ATR-BC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCPC ATR-BC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:PRUIETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 N FAIR ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-3130
Mailing Address - Country:US
Mailing Address - Phone:217-398-8090
Mailing Address - Fax:
Practice Address - Street 1:105 N FAIR ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821
Practice Address - Country:US
Practice Address - Phone:217-398-8090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.003668101YP2500X, 101Y00000X
NC00-105221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist