Basic Information
| Provider Information | |||||||||
| NPI: | 1710101936 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIBMA | ||||||||
| FirstName: | MARLENE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HIBMA | ||||||||
| OtherFirstName: | MARLENE | ||||||||
| OtherMiddleName: | JOHNSON | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LISW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2611 WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | PELLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416289599 | ||||||||
| FaxNumber: | 6416211493 | ||||||||
| Practice Location | |||||||||
| Address1: | 2611 WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | PELLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416289599 | ||||||||
| FaxNumber: | 6416211493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 00802 | IA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.