Healthcare Provider Details

I. General information

NPI: 1548892144
Provider Name (Legal Business Name): JUDEE MARIE ALEXANDER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 TOWER PARK DR
WATERLOO IA
50701-9098
US

IV. Provider business mailing address

945 TOWER PARK DR
WATERLOO IA
50701-9098
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-1230
  • Fax: 319-235-1229
Mailing address:
  • Phone: 319-235-1230
  • Fax: 319-235-1229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number01036
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: