Healthcare Provider Details

I. General information

NPI: 1235970815
Provider Name (Legal Business Name): STEPHEN HENKHAUS LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 JORDAN ST
NORTH LIBERTY IA
52317-8020
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 319-249-0307
  • Fax: 319-358-2367
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number124597
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: