1972625119 NPI number — MRS. CAROL GORDON WARMBIER LISW

Table of content: OSSI PACE MFT (NPI 1619100732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972625119 NPI number — MRS. CAROL GORDON WARMBIER LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WARMBIER
Provider First Name:
CAROL
Provider Middle Name:
GORDON
Provider Name Prefix Text:
MRS.
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:
GORDON
Provider Other First Name:
CAROL
Provider Other Middle Name:
ANN
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:
1972625119
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 474
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUMBOLDT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50548-0474
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-295-3334
Provider Business Mailing Address Fax Number:
515-295-3337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 E CALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALGONA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50511-2444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-295-3334
Provider Business Practice Location Address Fax Number:
515-295-3337
Provider Enumeration Date:
04/06/2007

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:  02481 , 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: 11764704 . This is a "CAQH" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 138200 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 252903 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 55339 . This is a "BLUE CROSS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1972625199 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2163631 . This is a "COMPSYCH" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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