Healthcare Provider Details

I. General information

NPI: 1114911591
Provider Name (Legal Business Name): KENNETH CLARK KOMYATHY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MDOS SGO 2501 CAPEHART ROAD
OFFUTT A F B NE
68113-1712
US

IV. Provider business mailing address

55 MDOS SGO 2501 CAPEHART ROAD
OFFUTT A F B NE
68113-1712
US

V. Phone/Fax

Practice location:
  • Phone: 402-294-7886
  • Fax: 402-232-7291
Mailing address:
  • Phone: 402-294-7886
  • Fax: 402-232-7291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1084
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: