Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 104100000X | Social Worker | ||
Y | 225XM0800X | Mental Health | 12342 | NE |
NPI | 1356767479 |
---|---|
Provider Name | Mike Smith |
First Address | Bellevue, NE 68147-2426 |
Second Address | Omaha, NE 68107-3402 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/03/2014 |
Last Update Date | 09/09/2020 |