Basic Information
| Provider Information | |||||||||
| NPI: | 1649991308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOSSELIN | ||||||||
| FirstName: | BRYCE | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PLMHP, PMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 N SAINT JOSEPH AVE | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689014451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024615024 | ||||||||
| FaxNumber: | 4024605829 | ||||||||
| Practice Location | |||||||||
| Address1: | 835 S BURLINGTON AVE STE 108 | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689016928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024637711 | ||||||||
| FaxNumber: | 4024615099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2022 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 7765 | NE | N | Behavioral Health & Social Service Providers | Social Worker | 101YM0800X | 13121 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.