Basic Information
| Provider Information | |||||||||
| NPI: | 1669816294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEGODT | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PMSW, PMHP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SUKUP | ||||||||
| OtherFirstName: | HEIDI | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PMSW, PMHP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 715 N SAINT JOSEPH AVE | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689014451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024605836 | ||||||||
| FaxNumber: | 4024605829 | ||||||||
| Practice Location | |||||||||
| Address1: | 835 S BURLINGTON AVE | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | HASTINGS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689016960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024637711 | ||||||||
| FaxNumber: | 4024615099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2013 | ||||||||
| LastUpdateDate: | 04/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 9428 | NE | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | 6773 | NE | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.