Basic Information
Provider Information | |||||||||
NPI: | 1922275650 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ABBE CENTER FOR CMH AT AGIN CT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 520 11TH ST NW | ||||||||
Address2: |   | ||||||||
City: | CEDAR RAPIDS | ||||||||
State: | IA | ||||||||
PostalCode: | 524053811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3193983562 | ||||||||
FaxNumber: | 3193983501 | ||||||||
Practice Location | |||||||||
Address1: | 3325 AGIN CT NE APT 5 | ||||||||
Address2: |   | ||||||||
City: | CEDAR RAPIDS | ||||||||
State: | IA | ||||||||
PostalCode: | 524028807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3193983562 | ||||||||
FaxNumber: | 3193983501 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2008 | ||||||||
LastUpdateDate: | 05/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KAESTNER | ||||||||
AuthorizedOfficialFirstName: | CINDY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3193983562 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LISW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 0074575 | 05 | IA |   | MEDICAID |