Provider Demographics
NPI:1225109309
Name:THULL, BRYCE THOMAS
Entity Type:Individual
Prefix:MR
First Name:BRYCE
Middle Name:THOMAS
Last Name:THULL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 S 99TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-1007
Mailing Address - Country:US
Mailing Address - Phone:402-393-0846
Mailing Address - Fax:
Practice Address - Street 1:11414 W CENTER RD
Practice Address - Street 2:SUITE 220
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4486
Practice Address - Country:US
Practice Address - Phone:402-330-4014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1568101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068631113Medicaid