Basic Information
| Provider Information | |||||||||
| NPI: | 1417115718 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFEWORKS INC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E EUCLID AVE | ||||||||
| Address2: | SUITE 151 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503134511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152558399 | ||||||||
| FaxNumber: | 5152558405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2008 | ||||||||
| LastUpdateDate: | 05/23/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STANLEY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5152558399 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIFEWORKS INC | ||||||||
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| AuthorizedOfficialCredential: | LISW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 04243 | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1001123 | 05 | IA | MEDICAID | 0469676 | 05 | IA | MEDICAID |