Healthcare Provider Details

I. General information

NPI: 1063051472
Provider Name (Legal Business Name): INTEGRATIVE PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20324 VETERANS DR STE 104
ELKHORN NE
68022-3552
US

IV. Provider business mailing address

20324 VETERANS DR STE 104
ELKHORN NE
68022-3552
US

V. Phone/Fax

Practice location:
  • Phone: 402-933-5700
  • Fax: 402-933-9998
Mailing address:
  • Phone: 402-933-5700
  • Fax: 402-933-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MACY KASPERBAUER
Title or Position: CEO
Credential: PMHNP-BC
Phone: 402-933-5700