Healthcare Provider Details

I. General information

NPI: 1992856132
Provider Name (Legal Business Name): BRENDA RENEE OLMSTED LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 N PARK PL NE SUITE 209
CEDAR RAPIDS IA
52402-6221
US

IV. Provider business mailing address

3494 QUAIL TRAIL CT
MARION IA
52302-9467
US

V. Phone/Fax

Practice location:
  • Phone: 319-377-2161
  • Fax: 319-377-2094
Mailing address:
  • Phone: 319-377-2161
  • Fax: 319-377-2094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06644
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: