Healthcare Provider Details

I. General information

NPI: 1699863894
Provider Name (Legal Business Name): BERNEETA L WAGONER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E WASHINGTON ST
CLARINDA IA
51632-1625
US

IV. Provider business mailing address

215 E WASHINGTON ST
CLARINDA IA
51632-1625
US

V. Phone/Fax

Practice location:
  • Phone: 712-542-3501
  • Fax: 712-542-4725
Mailing address:
  • Phone: 712-542-3501
  • Fax: 712-542-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number00391
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: