MEDICARE: DIANE SUE MANGOLD 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	06199	IA

General Provider Information

NPI Number	:	1972552917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE SUE MANGOLD LISW

Provider Business Mailing Address
First Line	:	201 E 11TH ST
Second Line	:
City	:	SPENCER
State	:	IA
Zip	:	51301-4436
Country	:	US
Telephone Number	:	712-262-2922
Fax Number	:	712-262-3826

Provider Business Practice Location Address
First Line	:	824 FLINDT DR
Second Line	:	SUITE 103
City	:	STORM LAKE
State	:	IA
Zip	:	50588-3208
Country	:	US
Telephone Number	:	712-732-3736
Fax Number	:	712-732-3275

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

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	07/21/2008

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