Provider Demographics
NPI:1174946743
Name:WAWREK, ELIZABETH (PSYD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WAWREK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SAN PEDRO DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5153
Mailing Address - Country:US
Mailing Address - Phone:720-295-8504
Mailing Address - Fax:
Practice Address - Street 1:8100 WYOMING BLVD NE
Practice Address - Street 2:STE M4 BOX #355
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1946
Practice Address - Country:US
Practice Address - Phone:720-295-8504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-01
Last Update Date:2015-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3883103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical