MEDICARE: MS. LORI DEGELAU 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	02741	IA

General Provider Information

NPI Number	:	1609132539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LORI DEGELAU LISW

Provider Business Mailing Address
First Line	:	1015 N 29TH ST
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-2839
Country	:	US
Telephone Number	:	515-570-8269
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 N 29TH ST
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-2839
Country	:	US
Telephone Number	:	515-570-8269
Fax Number	:

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

Provider Enumeration Date	:	04/04/2012
Last Update Date	:	05/29/2014

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