Provider Demographics
NPI:1134183510
Name:EAST IOWA PSYCHOLOGY GROUP PC
Entity type:Organization
Organization Name:EAST IOWA PSYCHOLOGY GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COOWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:319-358-9397
Mailing Address - Street 1:325 EAST WASHINGTON ST
Mailing Address - Street 2:STE 206
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240
Mailing Address - Country:US
Mailing Address - Phone:319-358-9397
Mailing Address - Fax:319-354-9626
Practice Address - Street 1:325 EAST WASHINGTON ST
Practice Address - Street 2:STE 206
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240
Practice Address - Country:US
Practice Address - Phone:319-358-9397
Practice Address - Fax:319-354-9626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA54264OtherWELLMARK
IA54264Medicare ID - Type Unspecified