Healthcare Provider Details

I. General information

NPI: 1740104249
Provider Name (Legal Business Name): FIRESIDE THERAPY COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 S 192ND ST STE 1014
ELKHORN NE
68022-3381
US

IV. Provider business mailing address

1017 S 192ND ST STE 1014
ELKHORN NE
68022-3381
US

V. Phone/Fax

Practice location:
  • Phone: 402-850-4755
  • Fax:
Mailing address:
  • Phone: 402-850-4755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: STACEY ANIELLO
Title or Position: OWNER
Credential: LIMHP
Phone: 402-850-4755