Healthcare Provider Details

I. General information

NPI: 1679534440
Provider Name (Legal Business Name): MARY THARP LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5264 COUNCIL ST NE
CEDAR RAPIDS IA
52402-2471
US

IV. Provider business mailing address

PO BOX 1824
CEDAR RAPIDS IA
52406-1824
US

V. Phone/Fax

Practice location:
  • Phone: 319-398-6575
  • Fax: 319-369-4673
Mailing address:
  • Phone: 319-369-4505
  • Fax: 319-369-4677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number03805
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier38918
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: