Provider Demographics
NPI:1215567094
Name:PRIMUS, JOANNA (TCADC)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:PRIMUS
Suffix:
Gender:F
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3362 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-2006
Mailing Address - Country:US
Mailing Address - Phone:319-235-6571
Mailing Address - Fax:
Practice Address - Street 1:3362 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-2006
Practice Address - Country:US
Practice Address - Phone:319-235-6571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA12062101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty