Provider Demographics
NPI:1619036860
Name:DELLWO, LARRY JOSEPH (MA)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JOSEPH
Last Name:DELLWO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:MRS
Other - First Name:EMILY
Other - Middle Name:TERESA
Other - Last Name:GUTZMANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:107 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-2343
Mailing Address - Country:US
Mailing Address - Phone:712-732-3775
Mailing Address - Fax:712-732-3775
Practice Address - Street 1:107 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-2343
Practice Address - Country:US
Practice Address - Phone:712-732-3775
Practice Address - Fax:712-732-3775
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA132231H00000X
IA209237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0086892Medicaid