Provider Demographics
NPI:1154666956
Name:PSYCHOLOGY SERVICES OF OTTUMWA LLC
Entity Type:Organization
Organization Name:PSYCHOLOGY SERVICES OF OTTUMWA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:479-530-7003
Mailing Address - Street 1:226 W MAIN ST STE 208
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-2503
Mailing Address - Country:US
Mailing Address - Phone:479-530-7003
Mailing Address - Fax:
Practice Address - Street 1:226 W MAIN ST STE 208
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-2503
Practice Address - Country:US
Practice Address - Phone:479-530-7003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001083103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB2309003Medicare PIN