Healthcare Provider Details

I. General information

NPI: 1376850016
Provider Name (Legal Business Name): GRANT THOMAS WILLMS M.MIN.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 FRANK ST
COUNCIL BLUFFS IA
51503-4460
US

IV. Provider business mailing address

2132 S 42ND ST
OMAHA NE
68105-2910
US

V. Phone/Fax

Practice location:
  • Phone: 712-323-4478
  • Fax: 712-323-4188
Mailing address:
  • Phone: 402-558-1858
  • Fax: 402-558-8970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number04986
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number04986
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number04986
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number04986
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number04986
License Number StateIA
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number04986
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: