Healthcare Provider Details

I. General information

NPI: 1740256718
Provider Name (Legal Business Name): DONNA L VAN PEURSEM LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 10TH ST
ROCK VALLEY IA
51247-1630
US

IV. Provider business mailing address

1905 10TH ST PO BOX 163
ROCK VALLEY IA
51247-1630
US

V. Phone/Fax

Practice location:
  • Phone: 712-476-5245
  • Fax: 712-476-9621
Mailing address:
  • Phone: 712-476-5245
  • Fax: 712-476-9621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06099
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: