Healthcare Provider Details

I. General information

NPI: 1891155602
Provider Name (Legal Business Name): ANNIE KAY VON GILLERN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8555 HARBACH BLVD STE 201
CLIVE IA
50325-1056
US

IV. Provider business mailing address

8555 HARBACH BLVD STE 201
CLIVE IA
50325-1056
US

V. Phone/Fax

Practice location:
  • Phone: 515-428-0775
  • Fax:
Mailing address:
  • Phone: 515-428-0775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06741
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: