Provider Demographics
NPI:1891155602
Name:VON GILLERN, ANNIE KAY (LISW)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:KAY
Last Name:VON GILLERN
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 1:8555 HARBACH BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-1056
Mailing Address - Country:US
Mailing Address - Phone:515-428-0775
Mailing Address - Fax:
Practice Address - Street 1:8555 HARBACH BLVD
Practice Address - Street 2:STE 201
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-1056
Practice Address - Country:US
Practice Address - Phone:515-428-0775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA067411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical