Healthcare Provider Details

I. General information

NPI: 1003812827
Provider Name (Legal Business Name): KEVIN MICHAEL GABBERT LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

300 W HUTCHINGS ST
WINTERSET IA
50273-2104
US

IV. Provider business mailing address

300 W HUTCHINGS ST
WINTERSET IA
50273-2104
US

V. Phone/Fax

Practice location:
  • Phone: 515-462-3105
  • Fax: 515-462-9265
Mailing address:
  • Phone: 515-462-3105
  • Fax: 515-462-9265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05978
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: