Healthcare Provider Details

I. General information

NPI: 1114913076
Provider Name (Legal Business Name): ELAINE GUMM LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 HICKMAN RD
DES MOINES IA
50314-1505
US

IV. Provider business mailing address

1801 HICKMAN RD
DES MOINES IA
50314-1505
US

V. Phone/Fax

Practice location:
  • Phone: 515-282-2319
  • Fax: 515-282-3234
Mailing address:
  • Phone: 515-282-2319
  • Fax: 515-282-3234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number01295
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: