Healthcare Provider Details

I. General information

NPI: 1053560581
Provider Name (Legal Business Name): JUDY B IWANIER MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 KELLER ST # 2
PETALUMA CA
94952-2349
US

IV. Provider business mailing address

1920 FALLBROOK LN
PETALUMA CA
94954
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-0736
  • Fax:
Mailing address:
  • Phone: 707-796-3511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18299
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: