Provider Demographics
NPI:1780211011
Name:LEISTER, MARY KATHLEEN (LMSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:LEISTER
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 1:1800 GRAND AVE APT 256
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-5040
Mailing Address - Country:US
Mailing Address - Phone:515-414-5337
Mailing Address - Fax:
Practice Address - Street 1:1200 VALLEY WEST DR STE 508
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1906
Practice Address - Country:US
Practice Address - Phone:515-414-5337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084478104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker