Healthcare Provider Details

I. General information

NPI: 1124375563
Provider Name (Legal Business Name): GERALD LOU MAYO III MSW, PLMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2012
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 W 21ST ST
SOUTH SIOUX CITY NE
68776-2652
US

IV. Provider business mailing address

917 W 21ST ST P.O. BOX 355
SOUTH SIOUX CITY NE
68776-2652
US

V. Phone/Fax

Practice location:
  • Phone: 402-494-3337
  • Fax: 402-494-3356
Mailing address:
  • Phone: 402-494-3337
  • Fax: 402-494-3356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9719
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6822
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: