MEDICARE: KATIE LEE BACON MA MASTER OF ARTS

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	101YP2500X	Professional Counselor	1721	NE
2	101YM0800X	Mental Health Counselor	3399	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	96065	OTHER	NE	BCBS

General Provider Information

NPI Number	:	1073652111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE LEE BACON MA MASTER OF ARTS

Provider Business Mailing Address
First Line	:	7501 O ST STE 100
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68510-2485
Country	:	US
Telephone Number	:	402-477-0651
Fax Number	:	402-477-0332

Provider Business Practice Location Address
First Line	:	7501 O ST
Second Line	:	SUITE 100
City	:	LINCOLN
State	:	NE
Zip	:	68510-2485
Country	:	US
Telephone Number	:	402-477-0651
Fax Number	:	402-477-0332

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

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	12/08/2023

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