Provider Demographics
NPI:1720028665
Name:WIERENGA-KELLER, SUZANNE (LISW)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:WIERENGA-KELLER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:
Other - Last Name:WIERENGA-KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:638 S BLUFF BLVD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-4742
Mailing Address - Country:US
Mailing Address - Phone:563-243-5633
Mailing Address - Fax:563-243-9567
Practice Address - Street 1:638 S BLUFF BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-4742
Practice Address - Country:US
Practice Address - Phone:563-243-5633
Practice Address - Fax:563-243-9567
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA042561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAQ48731Medicare UPIN