Provider Demographics
NPI:1114911591
Name:KOMYATHY, KENNETH CLARK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CLARK
Last Name:KOMYATHY
Suffix:
Gender:M
Credentials:LCSW
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Mailing Address - Street 1:55 MDOS SGO
Mailing Address - Street 2:2501 CAPEHART ROAD
Mailing Address - City:OFFUTT A F B
Mailing Address - State:NE
Mailing Address - Zip Code:68113-1712
Mailing Address - Country:US
Mailing Address - Phone:402-294-7886
Mailing Address - Fax:402-232-7291
Practice Address - Street 1:55 MDOS SGO
Practice Address - Street 2:2501 CAPEHART ROAD
Practice Address - City:OFFUTT A F B
Practice Address - State:NE
Practice Address - Zip Code:68113-1712
Practice Address - Country:US
Practice Address - Phone:402-294-7886
Practice Address - Fax:402-232-7291
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE10841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical