Provider Demographics
NPI:1497783625
Name:EKSTROM, DANIEL L (PSYS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:EKSTROM
Suffix:
Gender:M
Credentials:PSYS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 KIMBALL AVE
Mailing Address - Street 2:LL14
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5063
Mailing Address - Country:US
Mailing Address - Phone:319-272-1590
Mailing Address - Fax:319-272-1535
Practice Address - Street 1:2750 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5644
Practice Address - Country:US
Practice Address - Phone:319-272-8922
Practice Address - Fax:319-272-8929
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA433103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS18524Medicare UPIN
IAI0675Medicare PIN