NPIMap

Organization Active NPI

Elizabeth Wagner, PSYD, LP, Inc.

Doing business as ELEOS Psychology Center

  • Clinical Psychologist
  • St Louis Park, MN
National Provider Identifier
1740637818
Registry record updated Jul 1, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
5833 Issued in MN
Legal business name
ELIZABETH WAGNER, PSYD, LP, INC.
Doing business as
ELEOS Psychology Center
Practice address
4500 Park Glen Rd
Suite 450
Saint Louis Park, MN 55416-4871
Phone
(952) 444-9744
Fax
(952) 444-9745
NPI assigned
May 19, 2016
Last updated
Jul 1, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 1, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Elizabeth Wagner, PSYDNPI 1922128529
Title
Chief Executive Officer
Phone
(952) 444-9744

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X 5833 MN Primary

Addresses

Primary practice location

4500 Park Glen Rd
Suite 450
Saint Louis Park, MN 55416-4871

Mailing address

4500 Park Glen Rd
Suite 450
Saint Louis Park, MN 55416-4871
Phone (952) 444-9744

Other names 1

  • ELEOS Psychology Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190513002410 MN Part B Supplier - Clinic/Group Practice 4183967219 Receives reassigned benefits from 11 practitioners
Practice locations: Saint Louis Park, MN

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1463616000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1467331200000",
    "number": "1740637818",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4500 PARK GLEN RD",
            "address_2": "SUITE 450",
            "city": "SAINT LOUIS PARK",
            "state": "MN",
            "postal_code": "554164871",
            "telephone_number": "952-444-9744",
            "fax_number": "952-444-9745"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4500 PARK GLEN RD",
            "address_2": "SUITE 450",
            "city": "SAINT LOUIS PARK",
            "state": "MN",
            "postal_code": "554164871",
            "telephone_number": "952-444-9744",
            "fax_number": "952-444-9745"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ELIZABETH WAGNER, PSYD, LP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-05-19",
        "last_updated": "2016-07-01",
        "status": "A",
        "authorized_official_last_name": "WAGNER",
        "authorized_official_first_name": "ELIZABETH",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "952-444-9744",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PSYD"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "MN",
            "license": "5833",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ELEOS Psychology Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in St Louis Park, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 1, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.