MEDICARE: MRS. SUSAN JEAN MARVIN LISW

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	05865	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	113858	OTHER	IA	HEALTH ALLIANCE
2	1700416535	OTHER	IA	GEHA
3	257155	OTHER	IA	COMPSYCH
4	9385520	OTHER	IA	PRIVATE HEALTH CARE
5	244803	OTHER	IA	MIDLANDS CHOICE
6	39107	OTHER	IA	BLUE CROSS BLUE SHIELD
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	11472254	OTHER	IA	CAQH
9	5682627	OTHER	IA	FIRST HEALTH

General Provider Information

NPI Number	:	1285629709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN JEAN MARVIN LISW

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

Provider Business Practice Location Address
First Line	:	103 2ND AVE NE
Second Line	:
City	:	CLARION
State	:	IA
Zip	:	50525-1430
Country	:	US
Telephone Number	:	515-532-3338
Fax Number	:	515-532-3339

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

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	01/18/2013

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