1114911591 NPI number — MR. KENNETH CLARK KOMYATHY LCSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114911591 NPI number — MR. KENNETH CLARK KOMYATHY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOMYATHY
Provider First Name:
KENNETH
Provider Middle Name:
CLARK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114911591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 MDOS SGO
Provider Second Line Business Mailing Address:
2501 CAPEHART ROAD
Provider Business Mailing Address City Name:
OFFUTT A F B
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68113-1712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-294-7886
Provider Business Mailing Address Fax Number:
402-232-7291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 MDOS SGO
Provider Second Line Business Practice Location Address:
2501 CAPEHART ROAD
Provider Business Practice Location Address City Name:
OFFUTT A F B
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68113-1712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-294-7886
Provider Business Practice Location Address Fax Number:
402-232-7291
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  1084 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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