MEDICARE: MARY LOU PAINE PH.D., L.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	559	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5156	OTHER	NE	MIDLANDS CHOICE
2	98378	OTHER	NE	BCBS AUXILIARY
3	80077	OTHER	NE	BLUE CROSS BLUE SHIELD
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043224660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LOU PAINE PH.D., L.P.

Provider Business Mailing Address
First Line	:	1550 S 70TH ST
Second Line	:	SUITE 101
City	:	LINCOLN
State	:	NE
Zip	:	68506-1576
Country	:	US
Telephone Number	:	402-488-0077
Fax Number	:	402-488-0017

Provider Business Practice Location Address
First Line	:	1550 S 70TH ST
Second Line	:	SUITE 101
City	:	LINCOLN
State	:	NE
Zip	:	68506-1576
Country	:	US
Telephone Number	:	402-488-0077
Fax Number	:	402-488-0017

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	07/09/2007

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