Basic Information
| Provider Information | |||||||||
| NPI: | 1851552749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRUE | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUBBLES | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMHP, LADC, LIMHP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 333 W NORFOLK AVE | ||||||||
| Address2: | STE. 201 | ||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687015232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023792030 | ||||||||
| FaxNumber: | 4023791249 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 W NORFOLK AVE | ||||||||
| Address2: | STE. 201 | ||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687015232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023792030 | ||||||||
| FaxNumber: | 4023791249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 08/21/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 2342 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 504 | NE | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 391894354 | 05 | NE | MEDICAID |