Provider Demographics
NPI:1174696314
Name:THOMALLA, ERIC S (LADC805)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:S
Last Name:THOMALLA
Suffix:
Gender:M
Credentials:LADC805
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 N LINDEN ST
Mailing Address - Street 2:BLUE VALLEY BEHAVIORAL HEALTH
Mailing Address - City:WAHOO
Mailing Address - State:NE
Mailing Address - Zip Code:68066-1960
Mailing Address - Country:US
Mailing Address - Phone:402-443-4414
Mailing Address - Fax:402-443-3462
Practice Address - Street 1:543 N LINDEN ST
Practice Address - Street 2:BLUE VALLEY BEHAVIORAL HEALTH
Practice Address - City:WAHOO
Practice Address - State:NE
Practice Address - Zip Code:68066-1960
Practice Address - Country:US
Practice Address - Phone:402-443-4414
Practice Address - Fax:402-443-3462
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47052851504Medicaid
NE47052851502Medicaid
NE10025208700Medicaid
NE10025208000Medicaid