Basic Information
| Provider Information | |||||||||
| NPI: | 1063443976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GABBERT | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THALER | ||||||||
| OtherFirstName: | NANCY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 13TH AVE W STE 1 | ||||||||
| Address2: | |||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586014875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012277579 | ||||||||
| FaxNumber: | 7012277575 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 13TH AVE W STE 1 | ||||||||
| Address2: | |||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586014875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012277579 | ||||||||
| FaxNumber: | 7012277575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 11/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 347 | ND | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 54523 | 05 | ND | MEDICAID | 021455 | 01 | ND | BC/BS PIN | OTHER | 680014991 | 01 | RR MEDICARE PIN | OTHER |