Provider Demographics
NPI:1689454357
Name:VAN DE WALLE, KARMEN SUE
Entity Type:Individual
Prefix:
First Name:KARMEN
Middle Name:SUE
Last Name:VAN DE WALLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-3947
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1460 35TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-4731
Practice Address - Country:US
Practice Address - Phone:402-562-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor