Provider Demographics
NPI:1194819128
Name:TWO RIVERS PSYCHOLOGICAL SERVICES, PC
Entity Type:Organization
Organization Name:TWO RIVERS PSYCHOLOGICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-865-3027
Mailing Address - Street 1:4900 UNIVERSITY AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-3342
Mailing Address - Country:US
Mailing Address - Phone:515-277-5989
Mailing Address - Fax:515-277-6180
Practice Address - Street 1:4900 UNIVERSITY AVE STE 210
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311-3342
Practice Address - Country:US
Practice Address - Phone:515-277-5989
Practice Address - Fax:515-277-6180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00846103TC0700X
IA00187104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA=========Medicaid
IA=========Medicaid