Healthcare Provider Details

I. General information

NPI: 1902575913
Provider Name (Legal Business Name): KYLIE HEPP LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 E 7TH ST
CARROLL IA
51401-2524
US

IV. Provider business mailing address

201 E 11TH ST
SPENCER IA
51301-4460
US

V. Phone/Fax

Practice location:
  • Phone: 712-262-2922
  • Fax:
Mailing address:
  • Phone: 712-262-2922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number109573
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: