Provider Demographics
NPI:1093883431
Name:SMITH, DEBORRA MARIE (LISW)
Entity Type:Individual
Prefix:MS
First Name:DEBORRA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 1800TH ST
Mailing Address - Street 2:P.O. BOX #1
Mailing Address - City:PANAMA
Mailing Address - State:IA
Mailing Address - Zip Code:51562-6104
Mailing Address - Country:US
Mailing Address - Phone:712-489-2824
Mailing Address - Fax:712-243-4675
Practice Address - Street 1:1307 SUNNYSIDE LN
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-2205
Practice Address - Country:US
Practice Address - Phone:712-243-1213
Practice Address - Fax:712-243-4675
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0220301Medicaid
IA0220301Medicaid