Healthcare Provider Details

I. General information

NPI: 1790445021
Provider Name (Legal Business Name): TRISTATE COUNSELING & CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15320 WHITE OAK DR
PEOSTA IA
52068-7103
US

IV. Provider business mailing address

15320 WHITE OAK DR
PEOSTA IA
52068-7103
US

V. Phone/Fax

Practice location:
  • Phone: 319-330-1082
  • Fax:
Mailing address:
  • Phone: 319-330-1082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MELISSA M ANDERSON
Title or Position: OWNER OF ENTITY
Credential: MSW, LICSW
Phone: 319-330-1082