Provider Demographics
NPI:1770774978
Name:METTLIN, CONNIE ANN (LISW)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:ANN
Last Name:METTLIN
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 1:2151 NORWOOD ST
Mailing Address - Street 2:
Mailing Address - City:REINBECK
Mailing Address - State:IA
Mailing Address - Zip Code:50669-9682
Mailing Address - Country:US
Mailing Address - Phone:319-269-0554
Mailing Address - Fax:
Practice Address - Street 1:2151 NORWOOD ST
Practice Address - Street 2:
Practice Address - City:REINBECK
Practice Address - State:IA
Practice Address - Zip Code:50669-9682
Practice Address - Country:US
Practice Address - Phone:319-269-0554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA010831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1770774978Medicaid