=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417719212
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK ALLAN HONOMICHL PLMHP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2024
-----------------------------------------------------
Last Update Date | 01/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2201 N BROADWELL AVE
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68803-2153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-832-3660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 E 29TH ST APT 1
-----------------------------------------------------
City | KEARNEY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68847-3593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-830-2673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 13759
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------