Healthcare Provider Details

I. General information

NPI: 1568965580
Provider Name (Legal Business Name): CHAD ELBANDAGJI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CHAD MOHAMMAD LISW

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 STATE ST STE 202K
CEDAR FALLS IA
50613-3380
US

IV. Provider business mailing address

215 WALNUT ST
CEDAR FALLS IA
50613-2715
US

V. Phone/Fax

Practice location:
  • Phone: 619-559-5769
  • Fax: 319-575-6028
Mailing address:
  • Phone: 619-559-5769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110423
License Number StateIA

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: