Healthcare Provider Details

I. General information

NPI: 1295760189
Provider Name (Legal Business Name): NORMAN D OSTBLOOM LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7272 WURZBACH ROAD SUITE 601
SAN ANTONIO TX
78240-4803
US

IV. Provider business mailing address

125 S 3RD ST
AMES IA
50010-7042
US

V. Phone/Fax

Practice location:
  • Phone: 210-615-3428
  • Fax: 210-593-9863
Mailing address:
  • Phone: 515-232-5811
  • Fax: 515-232-7491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00782
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: