Healthcare Provider Details

I. General information

NPI: 1871354563
Provider Name (Legal Business Name): ELIZABETH D GIBBENS PLMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH STALLBAUMER

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 LAKE AVE
GOTHENBURG NE
69138-1943
US

IV. Provider business mailing address

714 E 17TH ST
COZAD NE
69130-1666
US

V. Phone/Fax

Practice location:
  • Phone: 308-537-3691
  • Fax:
Mailing address:
  • Phone: 308-746-2230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13768
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: