Healthcare Provider Details

I. General information

NPI: 1538836614
Provider Name (Legal Business Name): DEVIN WATERHOUSE LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 07/26/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105 NORTHPARK DR
JOHNSTON IA
50131-4807
US

IV. Provider business mailing address

9105 NORTHPARK DR
JOHNSTON IA
50131-4807
US

V. Phone/Fax

Practice location:
  • Phone: 515-984-0225
  • Fax: 515-984-0226
Mailing address:
  • Phone: 515-984-0225
  • Fax: 515-984-0226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number108217
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: