Provider Demographics
NPI:1043221914
Name:RUPPERT, EDWARD M (LISW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:M
Last Name:RUPPERT
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 COLORADO AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50014-2406
Mailing Address - Country:US
Mailing Address - Phone:515-292-9697
Mailing Address - Fax:970-294-4492
Practice Address - Street 1:113 COLORADO AVE STE 111
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50014-2406
Practice Address - Country:US
Practice Address - Phone:515-292-9697
Practice Address - Fax:970-294-4492
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA006531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA098935000Medicaid
IAR02989Medicare UPIN
IAI15849Medicare ID - Type Unspecified