Healthcare Provider Details

I. General information

NPI: 1962479220
Provider Name (Legal Business Name): DONALD JOSEPH KEHRWALD LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 10TH ST SE SUITE 201
LE MARS IA
51031-2550
US

IV. Provider business mailing address

1483 HARRISON DR
CHEROKEE IA
51012-7237
US

V. Phone/Fax

Practice location:
  • Phone: 712-546-4624
  • Fax:
Mailing address:
  • Phone: 712-225-5040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number01116
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier0178244
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: