Provider Demographics
NPI:1992034755
Name:FOURDYCE, TANA ASHLEY (LISW)
Entity Type:Individual
Prefix:
First Name:TANA
Middle Name:ASHLEY
Last Name:FOURDYCE
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 1:1706 BRADY ST STE 206
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-4708
Mailing Address - Country:US
Mailing Address - Phone:563-508-5205
Mailing Address - Fax:563-424-5453
Practice Address - Street 1:810 MAIN ST
Practice Address - Street 2:
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-1848
Practice Address - Country:US
Practice Address - Phone:563-320-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0069631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical