Provider Demographics
NPI:1508396391
Name:WILSON, ANDREA NICOLE NIEBUHR (LMSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE NIEBUHR
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 22ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:IA
Mailing Address - Zip Code:50009-1513
Mailing Address - Country:US
Mailing Address - Phone:319-360-9622
Mailing Address - Fax:
Practice Address - Street 1:3812 INGERSOLL AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-3400
Practice Address - Country:US
Practice Address - Phone:515-255-2500
Practice Address - Fax:515-255-7989
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA086286104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker