Basic Information
| Provider Information | |||||||||
| NPI: | 1215105762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASONGA | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MBULA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4102 GREENWOOD WAY | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6824223909 | ||||||||
| FaxNumber: | 6824223909 | ||||||||
| Practice Location | |||||||||
| Address1: | 828 CHIEF EDDIE HOFFMAN HWY | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436100 | ||||||||
| FaxNumber: | 9075436159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2008 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 20115 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1020986 | 05 | AK | MEDICAID | 88601L | 01 | TX | BLUECROSSBLUESHIELD PROV# | OTHER | 193427501 | 05 | TX | MEDICAID |