MEDICARE: ELIZABETH WAGNER, PSYD, LP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	5833	MN

General Provider Information

NPI Number	:	1740637818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELIZABETH WAGNER, PSYD, LP, INC.

Provider Business Mailing Address
First Line	:	4500 PARK GLEN RD
Second Line	:	SUITE 450
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-4871
Country	:	US
Telephone Number	:	952-444-9744
Fax Number	:	952-444-9745

Provider Business Practice Location Address
First Line	:	4500 PARK GLEN RD
Second Line	:	SUITE 450
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-4871
Country	:	US
Telephone Number	:	952-444-9744
Fax Number	:	952-444-9745

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	DR. ELIZABETH WAGNER
Credential	:	PSYD
Telephone Number	:	952-444-9744

Provider Enumeration Date	:	05/19/2016
Last Update Date	:	07/01/2016

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