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General NPI Number Information
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NPI Number | 1699863894
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Entity Type | Individual
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Provider Name | BERNEETA L WAGONER LISW
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Gender | Female
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 12/18/2007
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Provider Practice Location Address
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Address Line | 215 E WASHINGTON ST
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City | CLARINDA
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State | IA
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Zip | 51632-1625
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Country | US
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Telephone | 712-542-3501
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Fax | 712-542-4725
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Provider Business Mailing Address
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Address Line | 215 E WASHINGTON ST
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City | CLARINDA
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State | IA
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Zip | 51632-1625
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Country | US
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Telephone | 712-542-3501
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Fax | 712-542-4725
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 00391
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License Number State | IA
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