=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144821703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAULA S. GORDY LISW, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2020
-----------------------------------------------------
Last Update Date | 11/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 N 12TH ST STE 1
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52544-1439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-856-2688
-----------------------------------------------------
Fax | 641-856-2690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 N 12TH ST STE 1
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52544-1439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-856-2688
-----------------------------------------------------
Fax | 641-856-2690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAULA SUE GORDY
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 641-856-2688
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------