=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720848716
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEDARLOO MENTAL HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2024
-----------------------------------------------------
Last Update Date | 03/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 PLAZA CIR
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50701-5139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-505-8461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 PLAZA CIR
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50701-5139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-505-8461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TAMI HILL
-----------------------------------------------------
Credential | ARNP
-----------------------------------------------------
Telephone | 319-596-5765
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------