Healthcare Provider Details

I. General information

NPI: 1285694869
Provider Name (Legal Business Name): GREGORY LEE NOONEY MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3549 SOUTHERN HILLS DR
SIOUX CITY IA
51106-4736
US

IV. Provider business mailing address

PO BOX 5427
SIOUX CITY IA
51102-5427
US

V. Phone/Fax

Practice location:
  • Phone: 712-274-6729
  • Fax: 712-274-6744
Mailing address:
  • Phone: 712-274-6729
  • Fax: 712-274-6744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00710
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0205823
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: