Healthcare Provider Details

I. General information

NPI: 1811659873
Provider Name (Legal Business Name): KATIE KRUSEN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E 11TH ST
SPENCER IA
51301-4436
US

IV. Provider business mailing address

2840 S CORAL ST
SIOUX CITY IA
51106-3332
US

V. Phone/Fax

Practice location:
  • Phone: 712-262-2922
  • Fax:
Mailing address:
  • Phone: 712-490-0994
  • Fax: 712-226-1894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number100343
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100343
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: