MEDICARE: KRISTEN MAHANNAH LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	108399	IA

General Provider Information

NPI Number	:	1144995168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN MAHANNAH LISW

Provider Business Mailing Address
First Line	:	1900 SILVER LAKE RD NW STE 110
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-1789
Country	:	US
Telephone Number	:	651-628-9566
Fax Number	:	651-628-0411

Provider Business Practice Location Address
First Line	:	2545 N DODGE ST STE C
Second Line	:
City	:	IOWA CITY
State	:	IA
Zip	:	52245-9558
Country	:	US
Telephone Number	:	319-249-0307
Fax Number	:	319-358-2367

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2021
Last Update Date	:	03/30/2026

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