Healthcare Provider Details

I. General information

NPI: 1487473401
Provider Name (Legal Business Name): ATHENA R SPELLER LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3117 1ST AVE NE STE A
CEDAR RAPIDS IA
52402-4436
US

IV. Provider business mailing address

780 PARK CT
HIAWATHA IA
52233-1859
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-0898
  • Fax:
Mailing address:
  • Phone: 318-753-7567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150114558
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: