Provider Demographics
NPI:1902371727
Name:BROOKE GUNDRUM STORM MS PLMHP
Entity Type:Organization
Organization Name:BROOKE GUNDRUM STORM MS PLMHP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNDRUM STORM
Authorized Official - Suffix:
Authorized Official - Credentials:PLMHP
Authorized Official - Phone:531-242-9489
Mailing Address - Street 1:10866 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-1242
Mailing Address - Country:US
Mailing Address - Phone:531-242-9489
Mailing Address - Fax:
Practice Address - Street 1:10730 PACIFIC ST STE 30
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4761
Practice Address - Country:US
Practice Address - Phone:402-637-8024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-08
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty