Healthcare Provider Details

I. General information

NPI: 1760142384
Provider Name (Legal Business Name): JOSHUA RAY HEROLD LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 7TH ST BLDG 7
DES MOINES IA
50314-2503
US

IV. Provider business mailing address

PO BOX 80
POLK CITY IA
50226-0080
US

V. Phone/Fax

Practice location:
  • Phone: 515-697-7727
  • Fax:
Mailing address:
  • Phone: 515-371-9414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110416
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: