=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639820079
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRETCHEN MCBRIDE EDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2022
-----------------------------------------------------
Last Update Date | 01/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 14TH AVE
-----------------------------------------------------
City | NEBRASKA CITY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68410-1146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-873-6033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20107 S STABLE DR
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68347-4046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-830-2732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 2019011115
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------