Healthcare Provider Details

I. General information

NPI: 1275955304
Provider Name (Legal Business Name): MARCIA WULFEKUHLE IADC LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2014
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3362 UNIVERSITY AVE
WATERLOO IA
50701-2006
US

IV. Provider business mailing address

3362 UNIVERSITY AVE
WATERLOO IA
50701-2006
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-6571
  • Fax: 319-235-6028
Mailing address:
  • Phone: 319-235-6571
  • Fax: 319-235-6028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number85069
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number01281
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: