Healthcare Provider Details

I. General information

NPI: 1972008720
Provider Name (Legal Business Name): ALL THOSE YESTERDAYS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 STONEYBROOK CIR SW
SPENCER IA
51301-5806
US

IV. Provider business mailing address

22 STONEYBROOK CIR SW
SPENCER IA
51301-5806
US

V. Phone/Fax

Practice location:
  • Phone: 712-363-5886
  • Fax:
Mailing address:
  • Phone: 712-363-5886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: RYAN RICHARD JENSEN
Title or Position: COUNSELOR
Credential: (T)LMHC, IADC, CCDP
Phone: 712-363-5886