Healthcare Provider Details

I. General information

NPI: 1821105594
Provider Name (Legal Business Name): CYNTHIA A RURUP LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 W 3RD ST
GARNER IA
50438-1242
US

IV. Provider business mailing address

621 S ILLINOIS AVE SUITE 103
MASON CITY IA
50401-5489
US

V. Phone/Fax

Practice location:
  • Phone: 641-923-2651
  • Fax: 641-923-2652
Mailing address:
  • Phone: 641-494-3041
  • Fax: 641-494-3059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05835
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier43019
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: