Healthcare Provider Details

I. General information

NPI: 1386734507
Provider Name (Legal Business Name): DIANA SUE MCPECK LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 48TH ST STE 120
WEST DES MOINES IA
50266-6723
US

IV. Provider business mailing address

1701 48TH ST STE 120
WEST DES MOINES IA
50266-6723
US

V. Phone/Fax

Practice location:
  • Phone: 515-331-0303
  • Fax: 515-331-9086
Mailing address:
  • Phone: 515-331-0303
  • Fax: 515-331-9086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number01224
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: