Healthcare Provider Details

I. General information

NPI: 1548513187
Provider Name (Legal Business Name): AMANDA ERION LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 CENTER STREET
DES MOINES IA
50309
US

IV. Provider business mailing address

945 19TH ST
DES MOINES IA
50314-1117
US

V. Phone/Fax

Practice location:
  • Phone: 515-243-5181
  • Fax: 303-412-3371
Mailing address:
  • Phone: 515-241-0982
  • Fax: 515-241-0993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0000305
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCSW.09923106
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number092177
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: