Provider Demographics
NPI:1114141579
Name:PARENT ENRICHMENT PROGRAM
Entity Type:Organization
Organization Name:PARENT ENRICHMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT LISW
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VICKROY
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:515-250-9759
Mailing Address - Street 1:9339 LAKEWOOD CIRCLE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:IA
Mailing Address - Zip Code:50211-1867
Mailing Address - Country:US
Mailing Address - Phone:515-250-9759
Mailing Address - Fax:515-285-4876
Practice Address - Street 1:9339 LAKEWOOD CIRCLE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:IA
Practice Address - Zip Code:50211-1867
Practice Address - Country:US
Practice Address - Phone:515-250-9759
Practice Address - Fax:515-285-4876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IALISW01215104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0472548OtherMEDICAID MENTAL HEALTH WAIVER
IA0472548Medicaid
IA0733923Medicaid