Healthcare Provider Details

I. General information

NPI: 1649647199
Provider Name (Legal Business Name): KRISTINE MARIE DEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 03/17/2024
Certification Date: 03/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6751 SILVERCREEK DR
DAVENPORT IA
52806-1676
US

IV. Provider business mailing address

6751 SILVERCREEK DR
DAVENPORT IA
52806-1676
US

V. Phone/Fax

Practice location:
  • Phone: 563-293-6220
  • Fax:
Mailing address:
  • Phone: 563-320-3384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number072641
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: