Healthcare Provider Details

I. General information

NPI: 1003265067
Provider Name (Legal Business Name): NOLAN MARIE VITZTHUM MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 08/03/2024
Certification Date: 08/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 ELMHURST AVE
HUMBOLDT IA
50548-1882
US

IV. Provider business mailing address

1721 ELMHURST AVE
HUMBOLDT IA
50548-1882
US

V. Phone/Fax

Practice location:
  • Phone: 307-274-8705
  • Fax: 515-420-8303
Mailing address:
  • Phone: 515-450-2583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-1159
License Number StateWY

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: