Provider Demographics
NPI:1083873806
Name:FENDER, DANIEL G (LICSW)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:G
Last Name:FENDER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 CAPEHART RD
Mailing Address - Street 2:
Mailing Address - City:OFFUTT AFB
Mailing Address - State:NE
Mailing Address - Zip Code:68113-1043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 CAPEHART RD
Practice Address - Street 2:SUITE 2
Practice Address - City:OFFUTT AFB
Practice Address - State:NE
Practice Address - Zip Code:68113-1043
Practice Address - Country:US
Practice Address - Phone:402-274-8018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7872101YM0800X
NE64671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025559800Medicaid