Provider Demographics
NPI:1063721355
Name:MUCKLOW, GREG (MS)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:MUCKLOW
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 W 12TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-3660
Mailing Address - Country:US
Mailing Address - Phone:308-238-1428
Mailing Address - Fax:855-838-8884
Practice Address - Street 1:2217 W 12TH ST STE 4
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-3660
Practice Address - Country:US
Practice Address - Phone:308-238-1428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE969101YA0400X
NE1407101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)