1750588364 NPI number — MIRANDA SUE BOHLKEN LISW

Table of content: DAWN L SORIANO LCSW (NPI 1962017145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750588364 NPI number — MIRANDA SUE BOHLKEN LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOHLKEN
Provider First Name:
MIRANDA
Provider Middle Name:
SUE
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:
1750588364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3429 HEMLOCK PL NE
Provider Second Line Business Mailing Address:
APT. 1
Provider Business Mailing Address City Name:
CEDAR RAPIDS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52402-8816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-581-2673
Provider Business Mailing Address Fax Number:
866-387-3989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 LIBERTY WAY
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
NORTH LIBERTY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52317-9154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-665-2137
Provider Business Practice Location Address Fax Number:
319-665-2137
Provider Enumeration Date:
06/27/2007

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:  06264 , 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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