Provider Demographics
NPI:1376850016
Name:WILLMS, GRANT THOMAS (MMIN)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:THOMAS
Last Name:WILLMS
Suffix:
Gender:M
Credentials:MMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2132 S 42ND ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-2910
Mailing Address - Country:US
Mailing Address - Phone:402-558-1858
Mailing Address - Fax:402-558-8970
Practice Address - Street 1:20 FRANK ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4460
Practice Address - Country:US
Practice Address - Phone:712-323-4478
Practice Address - Fax:712-323-4188
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04986101Y00000X, 101YM0800X, 101YP1600X, 101YP2500X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist