Healthcare Provider Details

I. General information

NPI: 1245904341
Provider Name (Legal Business Name): ANDREA BLUNCK LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 12/28/2024
Certification Date: 12/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LOCUST ST PMB 126
DES MOINES IA
50309
US

IV. Provider business mailing address

PO BOX 672
ANKENY IA
50021-0672
US

V. Phone/Fax

Practice location:
  • Phone: 515-710-7894
  • Fax:
Mailing address:
  • Phone: 515-710-7894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number007500
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: