Healthcare Provider Details

I. General information

NPI: 1912111444
Provider Name (Legal Business Name): ANDREA LAWSON LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 S BLUFF BLVD
CLINTON IA
52732-4742
US

IV. Provider business mailing address

111 W 15TH ST
DAVENPORT IA
52803-4609
US

V. Phone/Fax

Practice location:
  • Phone: 563-243-5633
  • Fax: 563-243-9567
Mailing address:
  • Phone: 563-322-7419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number06464
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: