Provider Demographics
NPI:1700454121
Name:PRISM THERAPY GROUP LLC
Entity Type:Organization
Organization Name:PRISM THERAPY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PLADSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:319-361-9381
Mailing Address - Street 1:2886 61ST STREET LN LOT 4
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52349-9265
Mailing Address - Country:US
Mailing Address - Phone:319-361-9381
Mailing Address - Fax:
Practice Address - Street 1:1089 LONGFELLOW DR STE C
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-2032
Practice Address - Country:US
Practice Address - Phone:319-361-9381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-13
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA609919358Medicaid