=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508396391
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA NICOLE NIEBUHR WILSON LISW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2017
-----------------------------------------------------
Last Update Date | 08/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 PAINE CIR STE 6
-----------------------------------------------------
City | BONDURANT
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50035-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-373-4042
-----------------------------------------------------
Fax | 515-685-6449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 PAINE CIR STE 6
-----------------------------------------------------
City | BONDURANT
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50035-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-373-4042
-----------------------------------------------------
Fax | 515-685-6449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 086286
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------