Healthcare Provider Details

I. General information

NPI: 1841353604
Provider Name (Legal Business Name): TERESA MARIE GRIDER-BAKER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 C ST SW
CEDAR RAPIDS IA
52404-3707
US

IV. Provider business mailing address

760 PROSPECT CT
NORTH LIBERTY IA
52317-9128
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-9164
  • Fax: 319-368-3358
Mailing address:
  • Phone: 319-365-9164
  • Fax: 319-368-3358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05819
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier38246
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK
# 2
Identifier246645
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerMIDLAND'S CHOICE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: