Healthcare Provider Details

I. General information

NPI: 1992346019
Provider Name (Legal Business Name): MICHAEL DAVID STATE LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 UNIVERSITY AVE
DES MOINES IA
50314-2329
US

IV. Provider business mailing address

1111 UNIVERSITY AVE
DES MOINES IA
50314-2329
US

V. Phone/Fax

Practice location:
  • Phone: 515-288-1981
  • Fax:
Mailing address:
  • Phone: 515-288-1981
  • Fax: 312-943-6530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number108844
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.014149
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: