Basic Information
| Provider Information | |||||||||
| NPI: | 1508064080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BISHOP | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MA LMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17907 S 48TH ST | ||||||||
| Address2: | |||||||||
| City: | PLATTSMOUTH | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022987308 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5115 F ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023979866 | ||||||||
| FaxNumber: | 4023971404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 326LMHP | NE | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 47076510726 | 05 | NE | MEDICAID |