Provider Demographics
NPI:1699080549
Name:WAGNER, ELIZABETH ANNE (DPT)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2362 TWO NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2257
Mailing Address - Country:US
Mailing Address - Phone:803-799-7007
Mailing Address - Fax:
Practice Address - Street 1:2362 TWO NOTCH RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2257
Practice Address - Country:US
Practice Address - Phone:803-799-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6251225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist