Provider Demographics
NPI:1710432786
Name:OLDAG, LAUREN (LISW)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:OLDAG
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 SWAN LAKE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:INDEPENDENCE
Mailing Address - State:IA
Mailing Address - Zip Code:50644-9708
Mailing Address - Country:US
Mailing Address - Phone:563-212-8015
Mailing Address - Fax:319-332-1241
Practice Address - Street 1:2300 SWAN LAKE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:IA
Practice Address - Zip Code:50644
Practice Address - Country:US
Practice Address - Phone:563-212-8015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0774111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0074435Medicaid