1376683466 NPI number — MARCY COLLINS MENDENHALL LISW

Table of content: MARCY COLLINS MENDENHALL LISW (NPI 1376683466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376683466 NPI number — MARCY COLLINS MENDENHALL LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDENHALL
Provider First Name:
MARCY
Provider Middle Name:
COLLINS
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:
COLLINS
Provider Other First Name:
MARCY
Provider Other Middle Name:
COLLINS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LISW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376683466
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1441 W CENTRAL PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52804-1707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-320-0293
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1441 W CENTRAL PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52804-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-355-0293
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2007

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:  06137 , 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)