Healthcare Provider Details

I. General information

NPI: 1053118133
Provider Name (Legal Business Name): ELLIE JO CLOYED TCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2025
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1527 ALBIA RD
OTTUMWA IA
52501-3907
US

IV. Provider business mailing address

1527 ALBIA RD
OTTUMWA IA
52501-3907
US

V. Phone/Fax

Practice location:
  • Phone: 641-814-8731
  • Fax: 641-682-1924
Mailing address:
  • Phone: 641-680-8106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number245AP8336
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: