MEDICARE: NANCY BIRGITTA LAKE LISW, BCD

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	01439	IA

General Provider Information

NPI Number	:	1942270194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY BIRGITTA LAKE LISW, BCD

Provider Business Mailing Address
First Line	:	332 S LINN ST
Second Line	:	SUITE 17
City	:	IOWA CITY
State	:	IA
Zip	:	52240-1608
Country	:	US
Telephone Number	:	319-338-5181
Fax Number	:

Provider Business Practice Location Address
First Line	:	332 S LINN ST
Second Line	:	SUITE 17
City	:	IOWA CITY
State	:	IA
Zip	:	52240-1608
Country	:	US
Telephone Number	:	319-338-5181
Fax Number	:

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

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	09/14/2009

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