Provider Demographics
NPI:1699863894
Name:WAGONER, BERNEETA L (LISW)
Entity type:Individual
Prefix:MRS
First Name:BERNEETA
Middle Name:L
Last Name:WAGONER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-1625
Mailing Address - Country:US
Mailing Address - Phone:712-542-3501
Mailing Address - Fax:712-542-4725
Practice Address - Street 1:215 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-1625
Practice Address - Country:US
Practice Address - Phone:712-542-3501
Practice Address - Fax:712-542-4725
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00391104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6571310Medicaid
IA0427013OtherIOWA MEDICAID ENTERPRISE
7320OtherMIDLANDS CHOICE
129079OtherVALUE OPTIONS
58316OtherWELLMARK
SD6571310Medicaid