Healthcare Provider Details

I. General information

NPI: 1447857867
Provider Name (Legal Business Name): TROY ALLEN RAYMER LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2213 2ND ST
CORALVILLE IA
52241-1205
US

IV. Provider business mailing address

2213 2ND ST
CORALVILLE IA
52241-1205
US

V. Phone/Fax

Practice location:
  • Phone: 319-480-4956
  • Fax:
Mailing address:
  • Phone: 319-480-4956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number080102
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.028346
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: