Provider Demographics
NPI:1902109994
Name:WALLENBURG, DORIS A (LMSW)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:A
Last Name:WALLENBURG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 20TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK VALLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51247-1040
Mailing Address - Country:US
Mailing Address - Phone:712-541-3836
Mailing Address - Fax:712-707-9220
Practice Address - Street 1:1505 20TH ST
Practice Address - Street 2:
Practice Address - City:ROCK VALLEY
Practice Address - State:IA
Practice Address - Zip Code:51247-1040
Practice Address - Country:US
Practice Address - Phone:712-541-3836
Practice Address - Fax:712-707-9220
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0072321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical