Healthcare Provider Details

I. General information

NPI: 1205883303
Provider Name (Legal Business Name): NICOLE KEHOE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 E 29TH ST
DES MOINES IA
50317-4253
US

IV. Provider business mailing address

1200 UNIVERSITY AVE STE 200
DES MOINES IA
50314-2355
US

V. Phone/Fax

Practice location:
  • Phone: 515-248-1600
  • Fax: 515-248-1610
Mailing address:
  • Phone: 515-248-1447
  • Fax: 515-248-1440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number03738
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: