Provider Demographics
NPI:1205870508
Name:NEDOBA, BRIAN C (LISW)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:C
Last Name:NEDOBA
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2101 KIMBALL AVE
Mailing Address - Street 2:LL14
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5063
Mailing Address - Country:US
Mailing Address - Phone:319-272-1590
Mailing Address - Fax:319-272-1535
Practice Address - Street 1:217 20TH ST NW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2017
Practice Address - Country:US
Practice Address - Phone:319-352-9606
Practice Address - Fax:319-352-9610
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS18350Medicare UPIN
IAI4806Medicare PIN