Healthcare Provider Details

I. General information

NPI: 1013877075
Provider Name (Legal Business Name): BETHELEM CHUOL THOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2025
Last Update Date: 11/19/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2208 N WEBB RD # UNITS4
GRAND ISLAND NE
68803-1754
US

IV. Provider business mailing address

415 S CHERRY ST APT H45
GRAND ISLAND NE
68801-1905
US

V. Phone/Fax

Practice location:
  • Phone: 308-381-1690
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: