Healthcare Provider Details

I. General information

NPI: 1720634041
Provider Name (Legal Business Name): JOSHUA PROBST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 RISEN SON BLVD
COUNCIL BLUFFS IA
51503-1911
US

IV. Provider business mailing address

19865 BEVERLY MANOR LN
COUNCIL BLUFFS IA
51503-5495
US

V. Phone/Fax

Practice location:
  • Phone: 712-366-9655
  • Fax:
Mailing address:
  • Phone: 402-660-1681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number096671
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: