Provider Demographics
NPI:1366793606
Name:CONKINS, ELIZABETH ANNE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:CONKINS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 NODAK DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2366
Mailing Address - Country:US
Mailing Address - Phone:701-232-6224
Mailing Address - Fax:701-232-4687
Practice Address - Street 1:1112 NODAK DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2366
Practice Address - Country:US
Practice Address - Phone:701-232-6224
Practice Address - Fax:701-232-4687
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND40991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1454929Medicaid