1790900835 NPI number — REBECCA GOMPERT-FUNK LPC-MH

Table of content: REBECCA GOMPERT-FUNK LPC-MH (NPI 1790900835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790900835 NPI number — REBECCA GOMPERT-FUNK LPC-MH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOMPERT-FUNK
Provider First Name:
REBECCA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC-MH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOMPERT
Provider Other First Name:
REBECKA
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790900835
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3303 ROUGHLOCK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPEARFISH
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57783-9592
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-645-0141
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3303 ROUGHLOCK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPEARFISH
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57783-9592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-645-0141
Provider Business Practice Location Address Fax Number:
605-645-0141
Provider Enumeration Date:
04/16/2007

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: 101YM0800X , with the licence number:  LPC951 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4995828 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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