Healthcare Provider Details

I. General information

NPI: 1154666956
Provider Name (Legal Business Name): PSYCHOLOGY SERVICES OF OTTUMWA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2012
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 W MAIN ST STE 208
OTTUMWA IA
52501-2503
US

IV. Provider business mailing address

226 W MAIN ST STE 208
OTTUMWA IA
52501-2503
US

V. Phone/Fax

Practice location:
  • Phone: 479-530-7003
  • Fax:
Mailing address:
  • Phone: 479-530-7003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number001083
License Number StateIA

VIII. Authorized Official

Name: KATHLEEN T MURRAY
Title or Position: OWNER
Credential: PHD
Phone: 479-530-7003