Healthcare Provider Details

I. General information

NPI: 1902487739
Provider Name (Legal Business Name): MARISA MANSFIELD, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1926 W 4TH ST
DAVENPORT IA
52802-1628
US

IV. Provider business mailing address

1037 MEADOWVIEW LN
DAVENPORT IA
52806-2807
US

V. Phone/Fax

Practice location:
  • Phone: 563-362-2815
  • Fax:
Mailing address:
  • Phone: 563-676-8521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier082627
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerCLINICAL LICENSE

VIII. Authorized Official

Name: MRS. MARISA MANSFIELD
Title or Position: CLINICAL SOCIAL WORKER
Credential: LISW
Phone: 563-362-2815