Healthcare Provider Details

I. General information

NPI: 1972632768
Provider Name (Legal Business Name): SEAN G DEBOURCY LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
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

638 S BLUFF BLVD
CLINTON IA
52732-4742
US

V. Phone/Fax

Practice location:
  • Phone: 563-243-5633
  • Fax: 563-243-0936
Mailing address:
  • Phone: 563-243-5633
  • Fax: 563-243-0936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number06293
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: