Healthcare Provider Details

I. General information

NPI: 1760411060
Provider Name (Legal Business Name): LAWRENCE HEJTMANEK LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4908 FRANKLIN AVE
DES MOINES IA
50310-1901
US

IV. Provider business mailing address

2213 GRAND AVE
DES MOINES IA
50312-5305
US

V. Phone/Fax

Practice location:
  • Phone: 515-280-4930
  • Fax: 515-309-0686
Mailing address:
  • Phone: 515-237-3974
  • Fax: 515-883-2692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00096
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: