Provider Demographics
NPI:1548560584
Name:WESTERN PLAINS PSYCHOLOGY P.C.
Entity Type:Organization
Organization Name:WESTERN PLAINS PSYCHOLOGY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER/PRES.
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE-VIDLAK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:308-630-7966
Mailing Address - Street 1:P.O. BOX 1367
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69363-1367
Mailing Address - Country:US
Mailing Address - Phone:308-630-7966
Mailing Address - Fax:308-630-1028
Practice Address - Street 1:3911 AVE B, SUITE 3400
Practice Address - Street 2:SOUTH PLAZA
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361
Practice Address - Country:US
Practice Address - Phone:308-630-7966
Practice Address - Fax:308-630-1028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE605103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025891800Medicaid
NE10025891800Medicaid