1316767791 NPI number — LILY KATHRYN DEFOREST COLVIG LISW

Table of content: LILY KATHRYN DEFOREST COLVIG LISW (NPI 1316767791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316767791 NPI number — LILY KATHRYN DEFOREST COLVIG LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEFOREST COLVIG
Provider First Name:
LILY
Provider Middle Name:
KATHRYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316767791
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 LINCOLN WAY STE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50014-7595
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-239-4410
Provider Business Mailing Address Fax Number:
515-663-4885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8850 NW 62ND AVE STE 140
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50131-3178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-771-6194
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  113001 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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