MEDICARE: MARY ELIZABETH IVERSEN MSW

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	101YM0800X	Mental Health Counselor
2	104100000X	Social Worker		CO

General Provider Information

NPI Number	:	1861779340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELIZABETH IVERSEN MSW

Provider Business Mailing Address
First Line	:	10100 ELIDA RD
Second Line	:
City	:	DELPHOS
State	:	OH
Zip	:	45833-9056
Country	:	US
Telephone Number	:	419-695-8010
Fax Number	:	419-695-0004

Provider Business Practice Location Address
First Line	:	12500 E ILIFF AVE
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80014-1268
Country	:	US
Telephone Number	:	970-494-5891
Fax Number	:	970-494-5895

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

Provider Enumeration Date	:	11/10/2011
Last Update Date	:	12/05/2019

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