Healthcare Provider Details

I. General information

NPI: 1205900602
Provider Name (Legal Business Name): CYNTHIA SUE PETERS LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 1ST AVE NE
WAVERLY IA
50677
US

IV. Provider business mailing address

825 1ST AVE NE
WAVERLY IA
50677
US

V. Phone/Fax

Practice location:
  • Phone: 319-352-5839
  • Fax:
Mailing address:
  • Phone: 319-352-5839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number03238
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: