Healthcare Provider Details

I. General information

NPI: 1114423605
Provider Name (Legal Business Name): ALLISON KNUDTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 CLARK ST
DES MOINES IA
50314-1964
US

IV. Provider business mailing address

1409 CLARK ST
DES MOINES IA
50314-1964
US

V. Phone/Fax

Practice location:
  • Phone: 515-643-6500
  • Fax: 515-643-6589
Mailing address:
  • Phone: 515-643-6500
  • Fax: 515-643-6589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number421323808
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: