Basic Information
| Provider Information | |||||||||
| NPI: | 1760095152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | ELISABETH | ||||||||
| MiddleName: | P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4460 S HIGHLAND DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841243543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889494864 | ||||||||
| FaxNumber: | 2069012010 | ||||||||
| Practice Location | |||||||||
| Address1: | 4460 S HIGHLAND DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841243543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889494864 | ||||||||
| FaxNumber: | 2069012010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2020 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.