1699899906 NPI number — DIANE MCDONALD-GOETZMANN MSW, LISW

Table of content: DIANE MCDONALD-GOETZMANN MSW, LISW (NPI 1699899906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699899906 NPI number — DIANE MCDONALD-GOETZMANN MSW, LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDONALD-GOETZMANN
Provider First Name:
DIANE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, 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:
1699899906
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3501 HARRY LANGDON BLVD
Provider Second Line Business Mailing Address:
CHILD HEALTH SPECIALTY CLINICS
Provider Business Mailing Address City Name:
COUNCIL BLUFFS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51503-7837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-309-0041
Provider Business Mailing Address Fax Number:
712-309-0044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3501 HARRY LANGDON BLVD
Provider Second Line Business Practice Location Address:
CHILD HEALTH SPECIALTY CLINICS
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503-7837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-309-0041
Provider Business Practice Location Address Fax Number:
712-309-0044
Provider Enumeration Date:
03/19/2007

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:  02831 , 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: 01055 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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