Healthcare Provider Details

I. General information

NPI: 1568490761
Provider Name (Legal Business Name): LANA SUE LONG UNDERDONK LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LANA SUE LONG UNDERDONK LISW

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 11/07/2013
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

3500 OAKVIEW DR SUITE C
MUSCATINE IA
52761-5816
US

V. Phone/Fax

Practice location:
  • Phone: 563-243-5633
  • Fax: 563-243-9567
Mailing address:
  • Phone: 563-263-0351
  • Fax: 563-263-0361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number01213
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: