=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114141579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARENT ENRICHMENT PROGRAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 07/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9339 LAKEWOOD CIRCLE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50211-1867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-250-9759
-----------------------------------------------------
Fax | 515-285-4876
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9339 LAKEWOOD CIRCLE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50211-1867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-250-9759
-----------------------------------------------------
Fax | 515-285-4876
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT LISW
-----------------------------------------------------
Name | MRS. CATHERINE ANN VICKROY
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 515-250-9759
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LISW01215
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------