Provider Demographics
NPI:1972047074
Name:GORDY J WHITCOMB
Entity type:Organization
Organization Name:GORDY J WHITCOMB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHITCOMF
Authorized Official - Suffix:
Authorized Official - Credentials:LMHP LADC
Authorized Official - Phone:402-374-0245
Mailing Address - Street 1:1481 COUNTY ROAD 29
Mailing Address - Street 2:
Mailing Address - City:TEKAMAH
Mailing Address - State:NE
Mailing Address - Zip Code:68061-5030
Mailing Address - Country:US
Mailing Address - Phone:402-374-0245
Mailing Address - Fax:402-564-7735
Practice Address - Street 1:748 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-5004
Practice Address - Country:US
Practice Address - Phone:402-374-0245
Practice Address - Fax:402-564-7735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE436101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty