Healthcare Provider Details

I. General information

NPI: 1336721117
Provider Name (Legal Business Name): ALCOHOL & DRUG DEPENDENCY SERVICES OF SE IOWA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 04/22/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 MT. PLEASANT ST
BURLINGTON IA
52601
US

IV. Provider business mailing address

1340 MT. PLEASANT ST
BURLINGTON IA
52601
US

V. Phone/Fax

Practice location:
  • Phone: 317-753-6567
  • Fax: 319-753-0703
Mailing address:
  • Phone: 317-753-6567
  • Fax: 319-753-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: LENA JONES
Title or Position: ASSOC. DIRECTOR OF ADMIN
Credential:
Phone: 319-753-6567