Healthcare Provider Details

I. General information

NPI: 1376540591
Provider Name (Legal Business Name): LINDA S. KNIERIM LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 5TH AVE STE. 3
GRINNELL IA
50112-1604
US

IV. Provider business mailing address

719 5TH AVE STE. 3
GRINNELL IA
50112-1604
US

V. Phone/Fax

Practice location:
  • Phone: 641-236-3090
  • Fax:
Mailing address:
  • Phone: 641-236-3090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number00553
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: