MEDICARE: MR. DOUGLAS ALAN BRINK LISW, LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	05899	IA
2	106H00000X	Marriage & Family Therapist	0378	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	72639	OTHER	IA	WELLMARK BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1023013174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS ALAN BRINK LISW, LMFT

Provider Business Mailing Address
First Line	:	202 1ST ST SE
Second Line	:	SUITE 107
City	:	MASON CITY
State	:	IA
Zip	:	50401-3946
Country	:	US
Telephone Number	:	641-423-3778
Fax Number	:	641-423-3881

Provider Business Practice Location Address
First Line	:	202 1ST ST SE
Second Line	:	SUITE 107
City	:	MASON CITY
State	:	IA
Zip	:	50401-3946
Country	:	US
Telephone Number	:	641-423-3778
Fax Number	:	641-423-3881

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	08/12/2013

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