Healthcare Provider Details

I. General information

NPI: 1245088764
Provider Name (Legal Business Name): CORALVILLE COUNSELING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 22ND AVE STE 3
CORALVILLE IA
52241-1687
US

IV. Provider business mailing address

860 22ND AVE STE 3
CORALVILLE IA
52241-1687
US

V. Phone/Fax

Practice location:
  • Phone: 319-330-7227
  • Fax:
Mailing address:
  • Phone: 319-330-7227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. BOBBY JO SALM
Title or Position: OWNER, CEO, THERAPIST
Credential: LISW, RPT
Phone: 319-330-7227