Healthcare Provider Details

I. General information

NPI: 1174535793
Provider Name (Legal Business Name): MELISSA EASTMAN HUFF LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 N JACKSON ST
MT PLEASANT IA
52641-2063
US

IV. Provider business mailing address

301 W BURLINGTON AVE
FAIRFIELD IA
52556-3242
US

V. Phone/Fax

Practice location:
  • Phone: 319-385-8051
  • Fax: 319-385-7010
Mailing address:
  • Phone: 641-472-1684
  • Fax: 641-472-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06683
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier107314000
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerIOWA PLAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: