Provider Demographics
NPI:1477857704
Name:GOSHORN PSYCH-SERVICES PLLC
Entity Type:Organization
Organization Name:GOSHORN PSYCH-SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:GOSHORN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, ARNP
Authorized Official - Phone:641-205-3100
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:410 E ROBINSON ST
Practice Address - Street 2:SUITE A-2
Practice Address - City:KNOXVILLE
Practice Address - State:IA
Practice Address - Zip Code:50138-2058
Practice Address - Country:US
Practice Address - Phone:641-205-3100
Practice Address - Fax:641-205-3102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG-096742363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1255365631Medicaid
IA1255365631OtherWELLMARK BCBS
IAP01035746OtherRR MEDICARE
IA1255365631OtherWELLMARK BCBS