Healthcare Provider Details

I. General information

NPI: 1376717561
Provider Name (Legal Business Name): ELIZABETH L BRAGG LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 BROAD ST
SUMMERSVILLE WV
26651-1796
US

IV. Provider business mailing address

1305 WEBSTER RD
SUMMERSVILLE WV
26651-1125
US

V. Phone/Fax

Practice location:
  • Phone: 304-872-2090
  • Fax: 304-872-3590
Mailing address:
  • Phone: 304-872-6503
  • Fax: 304-872-5415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberAP00453140
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: