Provider Demographics
NPI:1902487630
Name:PLEDGEJOHNSON, DANIEL
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:PLEDGEJOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 LONGFELLOW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1720
Mailing Address - Country:US
Mailing Address - Phone:319-529-1543
Mailing Address - Fax:833-667-0184
Practice Address - Street 1:1030 5TH AVE SE STE 1200
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2428
Practice Address - Country:US
Practice Address - Phone:319-529-1543
Practice Address - Fax:833-667-0184
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1568058410Medicaid