1407940083 NPI number — MARY HENDERSHOTT L.I.S.W.

Table of content: MARY HENDERSHOTT L.I.S.W. (NPI 1407940083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407940083 NPI number — MARY HENDERSHOTT L.I.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSHOTT
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.I.S.W.
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:
1407940083
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2435 KIMBERLY RD.
Provider Second Line Business Mailing Address:
#165 SOUTH
Provider Business Mailing Address City Name:
BETTENDORF
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-362-2848
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2435 KIMBERLY RD
Provider Second Line Business Practice Location Address:
STE 165S
Provider Business Practice Location Address City Name:
BETTENDORF
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52722-3591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-362-2848
Provider Business Practice Location Address Fax Number:
563-888-5160
Provider Enumeration Date:
10/03/2006

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: 104100000X , with the licence number:  05287 , 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)

  • Identifier: 218643 . This is a "HEALTH ALLIANCE MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: I18118 . This is a "MEDICARE ID" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0283507 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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