Provider Demographics
NPI:1376683466
Name:MENDENHALL, MARCY COLLINS (LISW)
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:COLLINS
Last Name:MENDENHALL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:MARCY
Other - Middle Name:COLLINS
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:1441 W CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1707
Mailing Address - Country:US
Mailing Address - Phone:563-320-0293
Mailing Address - Fax:
Practice Address - Street 1:1441 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1707
Practice Address - Country:US
Practice Address - Phone:563-355-0293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA061371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical