Healthcare Provider Details

I. General information

NPI: 1124207097
Provider Name (Legal Business Name): GDC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 N 24TH ST
OMAHA NE
68110-2252
US

IV. Provider business mailing address

2505 N 24TH ST
OMAHA NE
68110-2252
US

V. Phone/Fax

Practice location:
  • Phone: 402-451-5549
  • Fax:
Mailing address:
  • Phone: 402-451-5549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1801957774
License Number StateNE

VIII. Authorized Official

Name: MRS. GAYAL DANETTE CHAMBERS
Title or Position: CEO
Credential: MHR
Phone: 402-451-5549