Provider Demographics
NPI:1932613254
Name:KATHERINE L. NYDAM OLIVIER, LISW LLC
Entity Type:Organization
Organization Name:KATHERINE L. NYDAM OLIVIER, LISW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:NYDAM OLIVIER
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:319-339-4757
Mailing Address - Street 1:757 W BENTON ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52246-5953
Mailing Address - Country:US
Mailing Address - Phone:319-339-4757
Mailing Address - Fax:
Practice Address - Street 1:757 W BENTON ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246-5953
Practice Address - Country:US
Practice Address - Phone:319-339-4757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1041CO700XMedicaid