Healthcare Provider Details

I. General information

NPI: 1427422260
Provider Name (Legal Business Name): THEA GUEST LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2015
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23751 HIGHWAY 30
CARROLL IA
51401-8505
US

IV. Provider business mailing address

515 PACIFIC AVE
AUDUBON IA
50025-1056
US

V. Phone/Fax

Practice location:
  • Phone: 712-792-9266
  • Fax: 712-792-1457
Mailing address:
  • Phone: 515-992-0511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number074609
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: