Healthcare Provider Details

I. General information

NPI: 1467663138
Provider Name (Legal Business Name): ROSEANNE IRENE FLAMM LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2213 E 52ND ST STE. B
DAVENPORT IA
52807-2785
US

IV. Provider business mailing address

8409 95TH AVE W
TAYLOR RIDGE IL
61284-9801
US

V. Phone/Fax

Practice location:
  • Phone: 563-355-4410
  • Fax: 563-355-4110
Mailing address:
  • Phone: 309-798-2960
  • Fax: 563-355-4110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number01175
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: