Provider Demographics
NPI:1104840347
Name:BLANKENBURG, MARY LOUISE (LISW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:BLANKENBURG
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:LOU
Other - Middle Name:
Other - Last Name:BLANKENBURG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW
Mailing Address - Street 1:PO BOX 1073
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52244-1073
Mailing Address - Country:US
Mailing Address - Phone:319-400-2268
Mailing Address - Fax:319-354-1679
Practice Address - Street 1:20 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-1821
Practice Address - Country:US
Practice Address - Phone:319-400-2268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA012831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0272708Medicaid
IA23547OtherWELLMARK/BCBS
IA0272708Medicaid