Provider Demographics
NPI:1508401274
Name:GUEDEGBE, REGIS
Entity Type:Individual
Prefix:
First Name:REGIS
Middle Name:
Last Name:GUEDEGBE
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 1:9020 HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-5412
Mailing Address - Country:US
Mailing Address - Phone:402-953-1631
Mailing Address - Fax:
Practice Address - Street 1:9020 HANOVER ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122-5412
Practice Address - Country:US
Practice Address - Phone:402-953-1631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-16
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities